THE  LIBRARY 

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OF  CALIFORNIA 

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Dr.  Jimil   Bogen 


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N 


DIAGNOSIS 

OF    THE 

MALIGNANT   TUMORS 

OF    THE 

ABDOMINAL   VISCERA 

BY 

PROFESSOR   RUDOLPH   SCHjMIDT 

PR0FP:SS0K  of  medicine  in  the  MNIVEKSITY  of  INNSBRUCK 

AUTHORIZED  ENGLISH   VERSION 

BY 

JOSEPH   BURKE,  ScD.,  M.D., 

ATTENDING    SURGEON,    BUFFALO    HOSPITAL    OF    THE    SISTERS    OF    CHARITY, 

CONSULTING    SURGEON,    EMERGENCY    HOSPITAL, 

BUFFALO,    N.    Y. 


NEW     YORK 
REBMAN    COMPANY 

herald    square    BUILDING 

141-145  West  36th  Street 


COPYHIGHT,    1913,    BY 

R  E  B  M  A  N     CO  M  P  A  N  Y 

New  York 

All  Rights  reserved 


PRINTED    IX    AMERICA 


Biomedical 
lib'-ary 


TABLE   OF  CONTEXTS 

A.  GENERAL    PART 


PAGE 


Physical  Examination  of  the  Abdomen  for  the  Presence  of  ]\Ialignant 

Tumor-Masses  and  Their  Resultant  Manifestations 1 

1.  External  Examination 1 

2.  Internal  Examination    6 

3.  X-ray  Examination 7 

Pseudo-Malignant  Abdominal  Diseases 10 

Chemical  Demonstration  of  Blood  in  the  Feces 1-t 

The  Diagnostic  Significance  of  Vegetable  and  Bacterial  Organisms  of 

the  Gastro-Intestinal  Tract 20 

Ehrlich's  "Diazo"  and  "Aldehyde"  Reaction 30 

Symptomatology  of  Cachexia  and  General  Symptoms 37 

Etiology  of  Malignant  Tumors    45 

Cell  Disposition 47 

Etiology  in  its  Narrower  Sense 49 

Etiologically  Important  Factors   in  the  Taking  of  Case   Histories 

of  Malignant  Neoplasms 55 

Prophylaxis  of  Malignant  Tumors 57 

Local  Hygiene 58 

General  Hygiene 59 

B.  SPECIAL    PART 

Cancer  of  the  Stomach 63 

Early  Symptoms '  63 

Physical  Examination  for  Gastric  Cancer 76 

V 


f;^fii094 


vi  TABLE    OF    CONTENTS 

PAGE 

Accompanying  Symptoms  from  Other  Organs 83 

Feces  and  Stomach  Contents    90 

Types  of  Disease,  Course  and  Duration 97 

Suspicious  Factors  and  Differential  Diagnosis 99 

Carcinoma  of  the  Large  Intestine 106 

Early  Symptoms 106 

Physical  Examination  for  Carcinoma  of  the  Large  Bowel 113 

Feces  and  Stomach  Contents 117 

Accompanying  Symptoms  from  Other  Organs 119 

Course,  Duration  and  Types 121 

Suspicious  Factors  and  Differential  Diagnosis    121 

Primary  and  Secondary  Cancer  of  the  Liver 125 

Early   Symptoms    125 

Physical  Examination  of  the  Liver 127 

Accompanying  Symptoms  from  Other  Organs    129 

Suspicious  Factors  and  Differential  Diagnosis    130 

Carcinoma  of  the  Gail-Bladder 133 

Early   Symptoms    133 

Physical  Examination  for  Cancer  of  the  Gall-Bladder 136 

Accompanying  Symptoms  from  Other  Organs 138 

Course,  Duration  and  Types 14-0 

Suspicious  Factors  and  Differential  Diagnosis    141 

Carcinoma  of  the  Pancreas 14-5 

Early   Symptoms    1-15 

Accompanying  Symptoms  from  Other  Organs 149 

Suspicious   Factors   and   Differential   Diagnosis 151 

Malignant  Tumors  of  the  Kidney 153 

Early  Symptoms 153 

Physical  Examination  of  the  Kidneys    .  156 

Accompanying  Symptoms  from  Other  Organs 158 

Course,  Duration   and  Types    160 


TABLE    OF    CONTENTS  vii 

PACE 

Suspicious  Factors  ,'ind  Differential  Diafrnosis 101 

"Ati/pical"  Malignant  Abdominal  Grozcths 165 

C.  CASE  HISTORIES 

Carcinoma  of  the  Stomach    174 

Carcinoma  of  the  Lar^e  Intestine 261 

A.  Cecum    261 

B.  Hepatic  Flexure    265 

C.  Splenic  Flexure   270 

D.  Si^noid  Flexure    271 

E.  Rectum 281 

Primary  Carcinoma  of  the  liiver 293 

Secondary  Carcinoma  of  the  Liver 302 

Carcinoma  of  the  Gall-Bladder,  Including  the  Biliary  Passages  and 

Papilla  of  Vater 304 

Carcinoma  of  the  Pancreas 327 

Malignant  Tumors  of  the  Kidneys 334 

APPENDIX 

Atypical  Malignant  New-Growths  in  the  Abdomen 343 

Index 357 


\ 


A.    GENERAL  PART 


Author's  Preface 


The  difig-nosis  of  a  malicrnunt  new  growth  ranks  among  the  most 
important  decisions  in  the  domain  of  abdominal  diseases.  Depending  on 
the  stage  of  the  disease,  it  may  mean  a  saving  of  life,  or  it  may  mean  a 
death  sentence. 

It  behooves  the  physician  to  avoid,  as  far  as  possible,  the  reproach 
of  not  having  recognized  in  time  the  malignant  nature  of  the  disease, 
making  a  life-saving  operation  impossible ;  but,  on  the  other  hand, 
the  patient  should  not  be  subjected  to  unnecessary  alarm  and  a  useless 
operation  through  an  erroneous  assumption  of  a  malignant  process. 

To  choose  the  right  path  between  these  two  extremes  of  possible  error 
belongs  to  the  most  difficult  problems  of  internal  medicine. 

Here  it  will  seem  proper  to  bridge  over  the  chasm  existing  between 
the  deep  knowledge  of  the  clinician  and  the  wide  field  of  the  general  prac- 
titioner. In  the  lattcr's  hands  lies  the  early  diagnosis  of  cancerous 
diseases,  for  it  is  his  judgment  that  the  patient  seeks  in  the  first  place. 

During  my  activities  of  more  than  ten  years  in  the  clinic  of  my 
honored  teacher,  Hofrat  Professor  Dr.  E.  v.  Neusser,  and  in  my  present 
capacity,  I  have  had  abundant  opportunity  to  gather  manifold  expe- 
riences in  regard  to  malignant  diseases  of  the  abdominal  organs.  I  was 
further  in  a  favorable  position  most  carefully  to  examine  the  various 
cases,  some  of  which  have  been  briefly  sketched  among  the  case  histories ; 
these  cases  being  in  connection  with  medical  post-graduate  work,  I  was 
able  to  compare  the  diagnostic  results  with  the  outcome  of  operative 
interference  and  autopsies. 

Thus  the  case  histories  to  be  appended  include,  almost  throughout, 
the  counter-findings  of  the  surgeon,  but  especially  those  of  the  anatomist. 
That  these  findings  come  from  the  latter  is  due  to  the  sad  fact  that 
most  cases  of  cancerous  disease  reach  the  clinic  when  it  is  too  late. 

In  going  over  the  history  of  the  symptoms  in  these  cases,  one  gains 
the  conviction  that  an  early  diagnosis  would  have  been  possible  had  it  not 
been  for  the  fact  that  the  medical  adviser,  through  no  fault  of  his  own, 
lacked  experience.  As  already  mentioned,  we  are  here  concerned  with 
one  of  the  most  difficult  chapters  of  internal  medicine,  in  which  some  de- 
gree of  certainty  can  be  acquired  only  after  years  of  special  study  and 
continued  control  by  means  of  autopsies  and  operations.  From  this 
point  of  view  I  believe  that  a  book  which  deals  with  this  subject,  not  as 
a  compilation,  but  from  the  author's  experience  of  many  years,  ought  not 
to  be  without  benefit. 


X  AUTHOR'S    PREFACE 

The  nature  of  the  subject,  through  the  numerous  diseases  entering 
into  differential  diagnosis  and  a  consideration  of  the  different  methods  of 
examination,  accounts  for  the  fact  that  the  scope  of  the  discussions  be- 
came somewhat  broadened,  so  that  the  underlying  work  partly  includes  a 
diagnostic  study  of  abdominal  diseases  in  general,  yet  has  in  view  par- 
ticularly the  malignant  processes. 

In  planning  the  book,  I  believe  I  have  everywhere  been  mindful  of  the 
problem  of  the  earliest  possible  diagnosis,  especially  in  the  case  of  gastric, 
intestinal  and  renal  neoplasms. 

In  the  case  histories,  the  symptoms  appearing  first  have  received  sharp 
emphasis,  and  I  considered  it  important  to  give  detailed  discussion  to  the 
diagnostic  value  of  the  subjective  phenomena  which  so  frequently  are  the 
forerunners  of  the  objective  findings. 

As  it  is  precisely  in  the  domain  of  malignant  neoplasms  that  prob- 
ability very  often  precedes  certainty  in  the  making  of  a  diagnosis,  I 
considered  it  to  the  point,  from  case  to  case,  to  emphasize  the  most  im- 
portant factors  of  suspicion,  especially  in  so  far  as  they  resulted  from 
the  condensation  of  simple  and  brief  reflections.  In  connection  with  this 
it  seemed  important  to  me  alwaj^s  to  include  in  the  calculations  the  con- 
stitutional peculiarity  of  the  patient.  In  view  of  the  wide  range  of  this 
subject,  exhaustive  references  to  the  literature  relating  to  it  would  have 
been  impossible  and  useless. 

At  the  same  time,  it  seemed  proper  here  and  there  to  gratify  the  de- 
sire for  further  information. 

The  current  efforts  at  cancer  diagnosis,  by  means  of  serum  reactions, 
have  not  been  included  in  this  work. 

These  experiments,  such  as  Brieger's  anti-trypsin  determination, 
Pfciffer's  anaphylaxis  test,  AscolVs  mejostagmin  reaction,  Crile's  isolysin 
demonstration,  etc.,  have  partly  been  recognized  as  not  available  for  can- 
cer diagnosis,  or  this  recognition  is  on  the  way. 

I  do  not  wish  to  detract  from  their  theoretical  interest. 

In  the  differential  diagnostic  discussions  it  seemed  of  great  practical 
importance  to  discriminate  between  the  existing  malignant  disease  and 
benign  affections,  at  the  same  time  giving  especial  attention  to  the  rela- 
tive frequency  of  possible  mistakes. 

As  multiplicity  should  be  avoided  in  diagnosis  it  has  been  my  con- 
stant endeavor,  in  the  differential  diagnosis,  to  point  out  the  most  acces- 
sible, briefest  and  most  certain  route. 

In  composing  this  book,  my  happiest  anticipation  was  that  it  might, 
in  a  modest  measure,  assist  in  early  diagnosis,  and  so  in  saving  the  life 
of  a  patient. 

Beyond  this  individual  interest,  however,  there  was  also  before  my 
eyes  the  great  question  of  the  cancer  problem.  The  more  improbable  the 
assumption  of  a  specific  cancer  excitant  becomes,  the  more  improbable 
also  the  assumption  that  the  cancer  problem  could  be  satisfactorily 
cleared  up  in  the  more  narrow  domain  of  laboratory  research.  In  those 
cases  where  questions  of  congenital  peculiarity,  hereditary  influences, 
dyscrasias,  etc.,  and  their  relations  to  the  genesis  of  cancer,  are  awaiting 


\ 


AUTHOR'S    PREFACE  xi 

solution,  an  advance  in  knowledge  can  be  expected  only  from  the  active 
co-operation  of  the  entire  profession,  and  especially  from  the  physician 
engaged  in  active  practice. 

So,  I  may  say,  that  beyond  the  individual  case  it  is  the  object  of  this 
book  to  promote,  in  a  modest  way,  the  general  interest  in  cancerous  dis- 
ease, thus  placing  the  question  of  cancer  research  on  the  broadest  pos- 
sible basis. 

DR.  RUDOLPH  SCHMIDT. 

Vienna. 


Translator's  Preface 


Our  close  personal  association  with  Professor  Schmidt  duriny-  a  two 
and  one  half  years'  (1899-1902)  service  in  the  clinic  of  the  late  Hofrat 
Professor  Edward  v.  Neusser,  gave  us  ample  opportunity  to  attest  with 
appreciation  the  thoroughness  of  scientific  detail  and  the  almost  uncanny 
diagnostic  ability  characteristic  of  both  Ncussei'  and  Schmidt.  One  could 
not  help  being  impressed  with  the  fact  that  diagnosis  was  always  of  para- 
mount interest  and  the  greatest  aim  of  a  clinic  whose  chiefs  were  Skoda, 
Bamberger,  Kahler  and  Neusser;  it  remained  for  Schmidt,  however,  as 
assistant  to  Neusser,  in  the  Vienna  General  Hospital  and  later,  as  Attend- 
ing Physician  to  the  Empress  Elizabeth  Hospital,  to  specialize  in  the 
study  and  diagnosis  of  abdominal  neoplasms. 

We  were  so  impressed  with  the  importance  of  Professor  Schmidt's 
book,  particularly  with  its  great  clinical  value  to  the  general  practitioner, 
whom  the  cancer  patient  first  consults,  that  we  determined  to  translate 
it  into  English. 

We  trust  our  efforts  will  be  appreciated  and  that  the  translation  will 
get  the  same  cordial  reception  in  America  as  the  original  did  in  Europe. 

We  wish  to  express  our  most  cordial  and  sincere  thanks  to  Dr.  Otto 
Rebescher,  without  whose  aid  w^e  could  not  possibly  have  completed  the 
work. 

JOSEPH  BURKE. 

Buffalo,  N.  Y. 


Physical  Examination  of  the  Abdomen  for  the 

Presence  of  Malignant  Tumor-Masses  and 

their  Resultant  Manifestations 

External  Examination 

Various  methods  of  external  examination  aim  at  removing,  at  least 
partially,  the  obstacles  which  the  abdominal  walls  place  in  the  way  of 
palpation.  Each  one  of  these  methods  strives  to  overcome  the  contrac- 
tion of  the  abdominal  nmscles,  be  it  active  or  reflex. 

Active  tension  of  the  abdominal  muscles  is  easily  caused  by  the  patient 
lying  on  his  back  and  raising  his  head  in  order  to  see  the  palpating  hand 
of  the  physician. 

Hence  the  first  rule:  The  head  of  the  patient  should  rest  without  a 
pillow  on  the  same  level  as  the  rest  of  the  body.  I  consider  it  quite  to 
the  point  to  request  the  patient  to  press  his  head  down  upon  the  table. 
In  this  way  one  most  effectively  overcomes  the  inclination  of  the  patient 
to  lift  his  head,  and  at  the  same  time  it  diverts  his  attention  from  the 
abdomen. 

Drawing  up  the  legs  may  sometimes  favor  relaxation  of  the  abdominal 
walls,  but  under  certain  conditions  may  also  have  the  opposite  effect 
if  the  legs  of  the  patient  are  in  a  position  that  is  too  tense. 

Examination  in  a  warm  bath  has  the  advantage  of  a  thorough  relax- 
ation of  the  abdominal  walls,  but  it  has  also  disadvantages :  the  head  of 
the  patient  is  elevated,  the  forearm  of  the  examiner  cannot  be  conven- 
iently placed  on  the  abdomen.  It  may  further  not  be  amiss  to  place  a 
thermophore  upon  the  abdomen  some  time  before  the  examination.  In 
this  way  considerable  relaxation  of  the  belly-walls  can  be  induced  even 
without  the  bath. 

As  all  anesthetics  may  be  dangerous  to  the  life  of  the  patient,  no 
matter  how  carefully  administered,  one  will  hardly  resort  to  this  extreme, 
though  radical,  method  for  purely  diagnostic  reasons ;  less  objection 
might  be  raised  against  the  subcutaneous  administration  of  morphin. 

Whoever  knows  how  to  palpate  well  will,  rarely  need  much  artificial 
help  in  producing  relaxation  of  the  belly-walls. 

The  most  frequent  cause  of  a  resistant,  tense  belly-wall  is  found  in 
a  harsh  method  of  palpation  which  is  unseemly  and  faulty. 

The  art  of  palpation  is  often  looked  upon  as  a  matter  of  course  and, 

as  compared  to  percussion  and  auscultation,  is  practised  altogether  too 

little. 

1 


2  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Aside  from  the  technique  of  palpation  there  are  also  certain  cases 
in  which  conditions  are  such  that  palpation  elicits  pain,  hence  muscular 
"defence,"  conditions  whicli  vary  from  time  to  time.  Thus,  for  instance, 
palpation  of  the  lower  abdominal  wall  may  be  very  painful,  owing  to  a 
distended  urinary  bladder,  hypertrophy  of  the  prostate,  etc. ;  hence  the 
rule:  first  empty  the  bladder,  especially  when  palpating  per  rectum  or 
per  vaginam. 

Even  aside  from  the  above,  the  condition  of  fulness  inside  of  the 
abdomen,  particularly  of  the  gastro-intestinal  tract,  is  of  great  im- 
portance. 

In  cases  of  gastric  ulcer  one  can  easily  convince  one's  self  that  the 
greatest  tenderness  on  pressure  is  observable-  when  meteorism  of  the 
stomach  is  present,  but  when  the  distended  walls  of  the  stomach  are 
enabled  to  relax  through  belching  of  gas  or  vomiting,  the  tenderness 
often  disappears  entirely. 

This  is  a  law  which  holds  good  in  all  ulcerating  conditions  of  the 
gastro-intestinal  tract,  and  is  therefore  also  applicable  to  gastro-intes- 
tinal carcinoma. 

Here  is  the  place  to  say  a  word  in  regard  to  the  practice  of  using 
effervescent  mixtures,  etc.,  in  an  effort  to  distend  the  stomach,  a  practice 
which  is  still  considerably  in  vogue. 

In  my  opinion  these  procedures  are  usuall}^  unpleasant  and  often 
dangerous  to  the  patient ;  they  can  almost  always  be  omitted  without 
detriment  to  a  diagnosis,  especially  when  it  is  feasible  to  make  an  exam- 
ination of  stomach  or  bowel  contents.  In  my  own  practice  I  have  not 
resorted  to  this  method  of  stomach  inflation,  -even  once,  in  a  great 
many  years. 

As  previously  mentioned,  palpation  becomes  painful  when  there  is 
distention  of  the  stomach  or  part  of  the  intestine  which  has  been  subject 
to  ulcerative  changes,  and  thus  is  rendered  more  difficult  by  the  reflex 
spasm  of  the  abdominal  walls.  In  this  way  hemorrhage,  and  even  per- 
foration, may  occur.  Frequently  inflation  is  resorted  to  in  order  to 
see  whether  and  how  a  tumor-mass  shifts.  However,  when  a  tumor-mass 
is  located  in  the  gastro-intestinal  tract  and  is  freely  movable,  its  "wan- 
dering" can  be  determined  by  making  examinations  at  different  times, 
on  an  empty  stomach  and  after  meals,  and  if  necessary  one  may  carefully 
give   food  which  causes   formation   of  gas,  such  as  bread. 

Neither  is  inflation  necessary  to  determine  the  presence  of  coils  of 
intestine  in  front  of  a  tumor-mass,  since  one  can  usually  detect  by  palpa- 
tion a  piece  of  gut  which  is  resting  upon  a  solid  base  such  as  the  kidney, 
spleen,  etc.,  especially  in  a  contracted  state. 

In  my  opinion,  therefore,  there  is  hardly  ever  a  reason  for  producing 
meteorism  by  artificial  inflation.  On  the  contrary,  though,  it  will  fre- 
quently be  found  necessary  to  remove  spontaneous  meteorism  by  some 
active  measures  or  through  vomiting,  defecation,  etc.,  because  it  increases 
abdominal  rigidity  when  there  are  ulcerative  processes  in  the  gastro- 
intestinal tract.     The  presence  of  gas  also  causes  much  tenderness. 

It  seems  important  to  me  to  emphasize  the  fact  that  the  customary 


PHYSICAL    EXAMINATION  3 

office  hours  of  physicians  are  very  unfavorable  for  palpating  gastric 
tumors.  Many  a  tumor  which  can  be  demonstrated  easily  after  the  small 
morning  collation  cannot  be  so  detected  in  the  afternoon  on  account  of 
the  full  and  inflated  condition  present.  In  cases  that  are  suspicious 
because  of  abdominal  enlargement,  I  consider  it  important  to  examine 
while  the  patient  is  fasting,  and  where  cancer  is  suspected  it  might  be 
well  to  examine  immediately  after  emptying  the  stomach  of  the  patient 
through  vomiting  or  by  means  of  the  stomach-tube. 

It  is  also  well  to  see  that  fermentable  food  be  avoided  as  far  as  pos- 
sible, and  milk  may  be  classed  as  such  at  times. 

When  there  is  insufficient  emptying  of  the  bowels  it  will  be  advisable 
to  soften  an}'  hardened  scybala  by  means  of  oil  enemata,  and  then  admin- 
ister a  cathartic  (phenolphthalein,  .5:1.0;  ricini  ca.,  15,  etc.).  In  this 
way  one  can  also  best  guard  himself  against  wrong  inferences  due  to 
old  sc^^bala  and  any  spastic  contractile  conditions  in  the  region  of  the 
large  bowel.  One  can  also  prevent  meteorism  from  interfering  with 
palpation  b}'  means  of  wet  packs  over  the  abdomen,  warm  sitz  baths, 
the  introduction  of  a  soft  rectal  tube,  or  the  administration  of  warm 
carminative  teas,  etc. 

The  less  the  stomach  and  intestine  are  distended  with  gases  the  more 
successful  will  be  tb.e  palpatory  examination  of  the  abdomen. 

One  point  which,  in  my  opinion,  is  too  little  borne  in  mind,  in  the 
technique  of  abdominal  palpation,  is  the  method  of  breathing. 

During  the  entire  time  of  palpation  it  should  be  of  a  diaphragmatic 
type.  Only  in  this  way  can  one  make  comparative  estimates  of  the 
so-called  "respiratory"  mobility. 

It  must  seem  evident  to  every  man  that  the  "respiratory"  mobility 
of  one  and  the  same  tumor  must  vary  according  to  whether  the  dia- 
phragm moves  extensively  downward  during  respiration  or  moves  but 
little,  as  is  the  case  during  breathing  which  is  chiefly  costal.  Hence  it 
would  be  more  proper  to  speak  of  "diaphragmatic  respiratory"  mobility, 
in  order  to  emphasize,  even  in  the  nomenclature,  that  the  unhindered 
action  of  the  diaphragm  here  pla3^s  an  important  role. 

A  most  efficacious  way  of  inducing  diaphragmatic  breathing  is  to 
place  one's  own  or  the  patient's  hand  on  his  epigastriimi,  requesting  him 
to  breathe  in  such  a  way  that  the  hand  is  raised  during  inspiration. 
With  all  those  enlargements  that  are  subject  to  movement  by  the  dia- 
phragm, palpation  is  to  be  carried  out  in  a  rliythmical  way ;  that  is, 
during  inspiration  as  well  as  expiration  the  palpating  hand  should  move 
in  a  direction  opposite  to  that  in  which  the  underlying  part  is  moving. 
Where,  for  instance,  one  is  dealing  with  a,  transversely  situated  cylin- 
drical tumor  of  the  pylorus,  the  palpating  fingers  are  laid  with  gentle 
pressure  just  underneath  tlie  suspected  place,  and  then  request  is  made 
for  deep  diaphragmatic  inspiration.  The  descending  cylindrical  tumor 
is  now  forced  against  the  palpating  finger-tips  which  finally  come  to 
rest  over  the  tumor.  During  this  entire  performance  the  fingers  will 
remain  in  the  same  place,  or  they  may  glide  upward  over  the  descending 
supposed  tumor  with  little  change  of  place. 


4  TUMORS    OF    THE    ABDOMINAL    VISCERA 

During  expiration,  the  tumor  returning  upward,  the  fingers,  which 
are  making  even  pressure  in  the  opposite  direction  (as  when  one  tears 
the  stem  from  a  cherry),  should  move  downward.  In  this  even,  rhythmical 
way  the  tumor  should  be  examined  during  several  inspirations  and  expi- 
rations as  to  its  form,  size,  consistency,  etc.  This  rhythmical  method 
of  palpation  has  the  great  didactic  advantage  of  getting  the  hand  of  the 
beginner  accustomed  to  rest,  thus  avoiding  that  aimless  boring  and 
punching  Avhich  is  too  often  seen,  even  among  more  advanced  practi- 
tioners. 

The  significance  of  forced  diaphragmatic  breathing  lies  also  in  the 
fact  that  during  the  forced  downward  movements  certain  tumors  lying 
behind  the  xiphoid  process  or  the  ribs  become  accessible  to  palpation. 

Of  great  importance  is  palpation  in  different  positions.  This  enables 
one  to  determine  the  degree  of  mobility  and  to  obtain  a  desirable  relaxa- 
tion of  the  muscles  of  the  abdomen,  thus  thinking  of  it  as  a  barrel,  the 
floor  of  which  carries  the  largest  burden. 

There  are  quite  prevalent  cei'tain  fallacies  in  regard  to  the  diagnostic 
value  of  ballottement,  as  found  among  others  in  kidney  tumors. 

The  larger  tumors  of  the  cecum  or  the  spleen  can  be  made  to  ap- 
proach the  palpating  hand  in  front  intcrmissively  in  the  antero-posterior 
direction  from  the  loins.  The  symptom,  after  all,  depends  upon  the 
antero-posterior  diameter  of  the  tumor-mass  and  its  more  lateral  situ- 
ation. Contact  of  the  same  with  the  back  is  a  particularly  favoring 
factor.  Corset  lobes  of  the  liver  not  seldom  produce  the  phenomenon 
of  ballottement,  of  course  more  in  a  slanting  direction  from  the  flanks 
(axillary  line)  forward,  although  ballottement  may  be  occasionally  elic- 
ited from  behind  with  an  organ  displaced  downward  or  through  inter- 
position of  downward  dislocated  kidney.  We  count  ballottement  of 
stomach  tumors  among  the  greatest  rarities,  yet  even  there  it  may  come 
under  observation. 

If  there  is  a  suspicion  of  a  malignant  neoplasm  in  the  abdomen,  the 
chief  object  is  to  determine  the  existence  of  a  tumor-mass;  then  other 
symptoms  resulting  from  its  presence  will  have  to  be  taken  into  con- 
sideration. 

It  is  well  at  the  first  examination  to  pay  attention  to  the  existence 
of  tender  pressure  points,  since  they  often  correspond  to  the  seat  of  the 
neoplasm. 

As  far  as  stomach  and  intestinal  carcinoma  are  concerned,  strict 
attention  must  be  paid  to  disturbances  in  the  calibre  of  the  canal  and 
the  resultant  signs.  Thus  we  meet  with  splashing  sounds,  which,  when 
localized  in  circumscribed  portions  of  the  intestine,  e.g.,  in  the  ascending 
colon,  may  occasionally  be  of  the  utmost  importance.  As  local  shaking 
is  in  many  cases  painful,  I  recommend  that  the  examination  be  made 
after  the  fashion  of  a  succussio  Hippocrates,  in  such  a  manner  that  the 
physician  takes  hold  with  both  hands  in  the  region  of  the  anterior  supe- 
rior spine  of  the  pelvis  and  shakes  evenly,  the  abdomen  being  parallel 
with  the  table.  The  ear  being  brought  near  to  the  abdomen,  one  can 
easily  determine  the  place  of  origin  of  the  splashing  sounds. 


PHYSICAL    EXAMINATION  5 

By  moans  of  the  broadly  iin[)osccl  hand  one  can  often  more  easily 
identify  localized  flatulence,  as  well  as  mild  peristalsis,  whether  it  be 
in  the  stomach  or  in  a  circumscribed  portion  of  the  intestine,  than  by 
inspection,  especially  when  there  is  bad  illumination. 

I  count  percussion  as  among  the  least  de|)endable  aids  in  physical 
examination  for  malignant  tumors   of  the  abdomen. 

It  is  often  entirely  impossible  to  establish  lines  of  demarcation  on 
account  of  the  close  and  irregular  juxtaposition  and  even  intermingling 
of  air-free   and   air-filled   tissue-masses   and   organs. 

Attention  may  here  be  called  to  the  fact,  which  to  my  knowledge 
has  not  received  cognizance,  that  in  dilatation  of  the  stomach,  hence  in 
pyloric  stenosis,  liver  dulness  is  greatly  diminished  without  assuming 
the  interposition  of  intestine  between  the  anterior  surface  of  the  liver 
and  the  belly-wall  or  border  of  the  liver  palpable  under  the  costal  arch. 

Only  in  cases  of  extensive  air-free  tumor-masses  is  there  any  pros- 
pect of  obtaining  resonance  which  belongs  to  the  tumor-mass,  and  even 
then  it  will  require  firm  application  of  the  pleximeter,  or  several  fingers, 
in  order  to  compress  the  interposed  gut,  light  percussion  being  made  over 
the  central  part  in  order  to  avoid  neighboring  portions  of  the  stomach 
and  intestines.  It  has  already  been  mentioned  that  slight  differences 
in  the  sound  obtained  in  the  flanks,  on  change  of  position,  are  not  to  be 
emplo3^ed  in  the  diagnosis  of  "ascites." 

As  far  as  changes  in  the  abdominal  wall  itself  are  concerned,  when 
there  is  a  suspicion  of  a  neoplasm,  particularly  if  enlargement  has  already 
been  demonstrated,  and  ascites  is  present,  one  should  never  omit  an 
examination  of  the  umbilicus  for  carcinomatous  infiltration.  There  is 
no  other  symptom  which  might  so  surely  and  easily  determine  the  dif- 
ferential diagnosis  between  "malignant,"  "tubercular"  and  "cirrhotic" 
ascites ;  even  though  this  is  not  one  of  the  common  symptoms,  yet  in 
cases  of  ascites  an  experienced  diagnostician  will  never  neglect  looking 
for  it. 

The  finding  of  epigastric  venous  enlargements  may  be  very  signific;int. 
These  are  most  frequently  found  in  connection  with  periportal  cirrhosis, 
but  ma}"  also  occur  with  malignant  processes  w^hich  are  mostly  intra- 
hepatic or  ad  portam.  They  are  of  especial  diagnostic  value  if  the  ma- 
lignant tumor-mass  is  centrally  located  in  the  liver  and  the  organ  itself 
shows  no  enlargement.  One  must  not  forget  that  the  cirrhoses  of  Laennec 
are  not  rare  as  a  complication  of  extra-hepatic  malignant  abdominal 
diseases. 

It  seems  to  me  that  altogether  too  little  notice  is  taken  of  auscul- 
tatory phenomena.  Full  attention  should  be  given  to  systolic  murmurs 
heard  in  the  epigastrium  in  gastric  and  hepatic  carcinoma,  occurring 
oftcncst,  according  to  my  ow^n  observation,  at  the  end  of  expiration, 
the  origin  of  these  murmurs  being  traced  partly  to  the  abdominal  aorta, 
partly  to  the  arteries  and  veins  supplying  the  larger  oi-gans.  Neither 
should  one  omit  examination  for  localized  peritoneal  friction-sounds  so 
frequently  occurring  in  tliis  region  with  stomach  and  intestinal  carcinoma 
and  liver-metastases. 


6  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Finally — for  the  sake  of  completeness — mention  must  be  made  of  the 
sense  of  smell  which  can  afford  diagnostic  aid  through  its  perceptions. 
Thus  Boas  singles  out  the  fact  that  in  cases  of  carcinoma  of  the  rectum 
the  parts  of  clothing  near  the  anus  give  off  not  merely  a  fecal  but  a 
fetid  odor,  the  reason  for  same  being  obvious. 

If  in  cases  of  stenosing  gastric  carcinoma  there  is  a  belching  of  gas, 
it  can  be  immediately  recognized  as  SH2  (the  odor  of  rotten  eggs).  In 
these  cases  there  is  usually  the  growth  of  sarcina*.  In  carcinoma  of  the 
esophagus,  the  expired  air  may  be  of  a  fetid  character. 

Internal  Examination 

Digital  examination  per  rectum  or  per  vaginam  should  never  be 
omitted  in  a  case  of  suspected  malignant  tumor  in  the  abdomen,  or 
when  this  diagnosis  has  already  been  established.  This  examination  is 
not  limited  to  cases  which  show  signs  of  a  neoplasm  growing  in  this 
region;  it  must  therefore  be  made  regardless  of  sucli  signs,  since  the 
ovaries  as  well  as  the  peritoneum  in  the  pouch  of  Douglas  are  not  seldom 
the  seat  of  metastases,  and  the  prognosis  of  a  case  or  the  question  of 
operability  is  not  rarely  decided  in  this  way.  One  must  not  lose  sight 
of  the  fact  also  tliat  carcinoma  of  the  rectum  may  remain  rather  latent 
for  a  long  time,  and  that  for  this  reason  alone  digital  examination  of 
the  rectum  appears  as  indicated  when  there  is  only  a  slight  suspicion 
of  such  a  malignant  condition.  We  find  carcinoma  of  the  rectum  in 
very  young  individuals,  even  in  those  in  the  twenties,  is  not  of  the 
greatest  rarity. 

Rectoromanoscopy 

Especiall}^  in  those  cases  where  tenesmus,  tenderness  on  pressure  over 
the  sigmoid  flexure,  the  presence  of  blood,  pus  and  mucus  in  the  feces 
point  to  a  deep-seated  catarrhal  ulcerative  disease,  whose  chronic  nature 
raises  the  suspicion  of  a  malignant  groAvth,  rectoromanoscopi/  ^  will  conic 
into  its  rights,  particularly  if  digital  examination  prove  negative. 

In  this  way  many  a  case  of  polypi,  catarrhal  ulceration,  etc.,  in  the 
lowermost  portion  of  the  intestine  has  been  properly  recognized ;  under 
its  guidance  it  will  also  be  possible  to  excise  portions  for  microscopical 
examination.  One  must  not  forget,  however,  that  the  danger  in  this 
method  of  examination  grows  commensurately  with  the  distance  one 
tries  to  reach  higher  up  in  the  bowel  (romanoscopy),  as  there  are  even 
cases  reported  in  the  literature  "  in  which  expert  examiners  have  thus 
brought  on  fatal  perforation,  not  only  in  ulcerated,  but  also  in  normal 
areas  of  the  intestinal  walls. 

Romanoscopy,^  therefore,  is  indicated  only  when  there  is  great  prob- 
ability of  gaining  a  decided  advantage  for  the  patient.  It  would  be 
desirable  to   consider  romanoscopy  as  belonging  to  the  domain   of  sur- 

'  Compare  Schreiber,  Sammlung  zwangl.  Abhandl.  a.  d.  Geb.  d.  Verd. — u.  Stoff- 
wechselerkr.,  Albu.  I.  Bd.,  H.  1/2,  1908. 

'  For  obvious  reasons  similar  cases   are  unfortunately  but  rarely  reported. 

^  For  such  a  case  see  Anschiitz,  Beitrage  zur  Klinik  des  Dickdarmkrebses. — Mitt. 
;ius  d.  Grenzgeb.  d.  Medizin  u.  Chirurgie.    III.  Supplementth.,  Jena,  1907,  p.  508. 


PHYSICAL    EXAMINATION  7 

gerj,  so  that  in  case   of  rupture,  life-saving  laparotomy  could   be   per- 
formed immediately. 

Profuse  intestinal  hemorrhage  as  well  as  acute  inflammator}'  pro- 
cesses should  always  be  regarded  as  contraindications  to  instrumental 
examination. 

X-Ray  Examination 

With  respect  to  the  value  of  radiological  examination  in  regard  to 
abdominal  diseases  in  general,  and  gastro-intestinal  affections  in  par- 
ticular, it  would  seem  that  at  the  present  time  there  are  prevalent  some 
rather  exaggerated  notions,  not  only  among  the  laity,  but  also  in  the 
medical  profession. 

Whoever  occupies  himself  with  a  single  method  of  examination  will 
ride  his  hobb}-  to  the  danger  of  esteeming  it  too  highly. 

It  would  be  commendable  to  allow  for  this  psychological  factor  in 
radiological  publications. 

Indiscriminate  X-raying  of  the  abdomen  in  any  and  every  case  can 
only  lead  to  quackery  or — because  of  the  frequency  of  useless  negative 
results — bring  discredit  on  this  method  of  examination,  in  both  instances 
equally  regrettable.  Therefore,  as  in  operative  interference,  so  also 
in  radiographic  examinations,  one  should  not  proceed  without  indica- 
tions. This  course  is  justified,  since  the  method  itself  is  not  without 
danger,  as  besides  local  burns,  deaths  have  occurred  from  the  admin- 
istration of  the  customary  doses  of  bismuth  (30-50  g.). 

In  deciding  upon  the  indications,  one  will  have  to  bear  in  mind  that 
a  thick  belly  is  less  adapted  for  X-ray  examination  than  a  lean  one. 

Where  it  is  a  question  of  shape,  location  and  size  of  the  stomach, 
the  sovereign  method,  certainly  the  most  convenient  for  the  operator, 
is  the  X-raying  of  the  bismuth-filled  stomach. 

After  these  findings  have  been  settled  upon,  however,  very  little  or 
nothing — with  some  exceptions — has  been  gained  that  will  aid  in  the 
final  diagnosis,  especially  as  far  as  the  three  most  important  diagnoses 
are  concerned,  namely:  ulcer,  carcinoma,  neurosis. 

The  diagnosis  of  ulcer,  and  that  with  which  we  are  here  concerned, 
viz.,  carcinoma  of  the  stomach,  will  have  to  be  made  from  consideration 
of  the  sum  total  of  our  clinical  findings,  A  particular  value  is  ascribed 
in  the  clinical  picture  to  occult  intestinal  hemorrhages,  because  a  repeated 
negative  finding  makes  a  recent  ulcerative  process  in  the  stomach  im- 
probable. 

If  an  exhaustive  clinical  examination  offers  nothing  to  support  the 
probability  of  carcinoma  then  the  X-ray  will  hardly  disclose  anything 
further. 

If  the  presence  of  a  gastric  tumor,"*  together  with  persistent  occult 
hemorrhage  and  the  remaining  symptoms,  is  clear,  one  can  well  save  the 
patient  the  annoyance  of  a  bismuth  meal. 

Quite  different  are  those  cases  in  which  there  is  slight  or  moderate 

*  Its  recognition  is  not  so  diflBcult  a*  occasionally  described   in   radiological   works. 


8  TUMORS    OF    THE    ABDOMINAL    VISCERA 

probability  of  gastric  cancer  and  where  careful  clinical  analyses  yield 
no  further  data.  In  such  cases  it  would  be  of  the  greatest  importance 
if  the  clinical  work  could  be  actually  benefited  by  radiograph}'. 

This,  however,  is  generally  not  the  case,  as  is  shown  by  the  recog- 
nition of  the  symptoms  which  make  the  radiologist  suspicious  of  car- 
cinoma. The  fact  must  not  be  overlooked  that  as  sources  of  error  in 
methods  of  examination,  radiology  ranks  among  those  that  head  the 
list.  When  reference  was  made  to  the  radiologist's  suspicion  of  car- 
cinoma it  was  really  saying  too  much. 

Observation  of  the  bisnmth  mass  in  the  stomach  and  observation  of 
peristalsis  in  the  greater  curvature  will  occasionally  yield  the  following 
diagnostic  points:  1.  Processes  altering  the  lumen  existing  in  the  wall, 
or  in  or  outside  the  stomach  cavity.  2.  Stenosis  at  the  pylorus.  3.  Ex- 
clusion of  a  portion  of  the  wall  in  the  normal  peristalsis.  How  and 
where  arc  these  details  of  observation  applied  in  cancerous  disease  of 
the   stomach? 

1.  Not  seldom  cancers  are  ulcer-like  and  may  attract  attention  by 
occult  intestinal  hemorrhages,  but  without  causing  any  alterations  in 
the  calibre  of  the  organ.  Even  advanced  cancers  may  spread  on  the 
surface  without  encroaching  upon  the  lumen  of  the  part.  As  a  rule,  it 
will  be  only  in  far-advanced  cases  of  gastric  cancer  that  we  can  find  a 
decided  encroachment  upon  the  hunen  with  eventual  filling  of  the  antrum 
or  contraction  with  formation  of  an  hour-glass  stomach  and  deficient 
expansibility  of  the  cardia.  It  is  from  such  cases  that  the  illustrations 
in  the  literature  ''  have  been  obtained. 

In  such  advanced  cases  one  may  eventuall}'  succeed,  in  carcinoma 
of  the  pars  media  for  instance,  in  demonstrating  an  hour-glass  stomach 
which  in  itself  may,  of  course,  be  benign.  In  differential  diagnosis,  for 
that  matter,  regard  nmst  also  be  had  for  the  "spastic"  hour-glass  stom- 
ach due  to  a  local  lesion  of  the  stomach-wall,  such  as  erosion,  but  which 
may  be  purely   functional   at   the  time  of  the  examination. 

In  addition  to  clinical  phenomena,  such  as  difficulty  in  swallowing 
and  in  the  introduction  of  the  stomach-tube,  advanced  carcinoma  of 
the  cardia  may,  by  means  of  the  X-ray,  show  deficient  expansion. 

Defective  "filling-in"  of  the  antrum  pylori  will  have  to  be  judged 
cautiously,  inasmuch  as  it  is  only  seldom  a  real  expression  of  narrowing 
in  the  early  stage  of  pyloric  cancer. 

Conditions  would  be  simple  if  the  stomach  were  a  U-shaped  tube 
with  a  smooth  wall,  of  definite  shape  with  easily  movable  contents.  But 
the  inner  wall  is  much  convoluted  in  changing,  and  at  times  spastic, 
states  of  contraction,  and  the  contents  tenacious. 

The  above  makes  apparent  the  necessity  of  the  greatest  scepticism  in 
regard  to  anomalies  in  the  state  of  fulness  and  the  border  of  the  shadow 
in  the  antrum  pylori,  the  shape  of  which  is  not  always  a  definite  one. 

Besides,  in  order  to  obtain  the  best  unfolding,  one  must  help  by 
means    of   right-sided    position,    massage,    etc.,    factors    whose    efficiency 

''See  E.  Shiifz,   Weiner   Klin.  Wochensch.,   1906.     No.   14.. 


PHYSICAL    EXAMINATION  9 

varies  from  time  to  time.  Naturally  the  ability  to  unfold  may  be  en- 
hanced by  bending,  spasms,  and  compression  from  without. 

Far-advanced  diffuse  infiltrating,  scirrhus  carcinomata  of  the  stom- 
ach, which,  for  that  matter,  will  also  give  characteristic  clinical  data, 
will  show  up  in  the  X-ray  a  stomach  much  diminished  in  size. 

2.  jNIanifestation  of  pyloric  stenosis  does  not  figure  among  the  early 
symptoms  of  pyloric  cancer;  on  the  other  hand,  clinically  they  may  be 
diagnosed  with  great  probability  from  the  subjective  symptoms  as  shown 
by  me  in  the  treatise  of  colic  from  pyloric  stenosis.'' 

However,  according  to  the  latest  observations,  it  seems  that  spasms 
of  the  p3'lorus  ~  (without  any  anatomical  stenosis)  can  give  the  same 
results. 

Only  a  positive  finding  is — with  caution — of  value.  Even  in  cases 
of  clinically  genuine  pyloric  stenosis,  "antiperistalsis"  may  be  missing. 

As  a  result  of  solid  infiltration,  or  cicatricial  induration,  especially 
when  the  anatomical  process  has  already  penetrated  the  muscularis, 
there  is  a  theoretic  possibility  that  a  circumscribed  portion  of  the  stom- 
ach, e.g.,  the  antrum  pylori,  may  not  take  part  i"n  peristalsis.  Even 
here,  for  that  matter  in  most  cases,  one  may  be  dealing  with  advanced 
cases  of  cancer  of  the  stomach. 


The  foregoing  deductions  are  not  intended  to  discourage  radiological 
examination  *^  as  useless  when  there  is  suspicion  of  a  gastric  cancer,  but 
rather  to  point  out  its  proper  limits  of  employment  and  to  warn  against 
undue  expectations. 

In  classifying,  according  to  merit,  the  diagnostic  measures  that  will 
aid  in  the  determination  of  gastric  cancer,  radiology  finds  a  place  at 
the  bottom  of  the  list.  The  clinical  methods  of  examination  come  first. 
After  they  have  been  exhausted  then  may  come  cases  in  which  there 
is  an  indication  for  X-ray  examination. 

Still  less  are  there  prospects  of  real  gain  for  diagnosis  in  malignant 
diseases  of  the  large  bowel,  although  during  their  entire  course  there 
may  be  demonstration  of  their  existence. 

The  best  chance  for  radiological  findings  may  be  in  the  cases  of  ring- 
shaped,  obstructing  neoplasms  especially  peculiar  to  the  sigmoid  flexure. 

Neoplasms  of  the  liver,  the  gall-ducts,  pancreas,  as  well  as  retro- 
peritoneal enlargements,  find  no  place  in  these  considerations. 

Where  one  faces  a  diflFerential  diagnosis  of  "attacks  of  colic  resulting 
from  nephrolithiasis  or  of  a  neoplasm  in  the  kidney,"  it  would  be  ad- 
visable to  employ  the  X-ray  because  of  the  easy  demonstration  of  stones 
in  the  kidney  (uratic  calculi  included). 

*i?.  Schmidt.  Die  Schmerzphenomene  bei  inneren  Krankheiten,  etc..  AV.  Brau- 
mueller,   1906,  page  142. 

'  R.  Bauer,  Beitrage  zur  Symptomatologie  des  Ulc.  Ventric,  Wiener  nied.  Wocli., 
1910,   No.   15. 

'  Grosse  Verdienste  iim  die  Rontgen  Diagnostic  der  Magenkrankheiten  hat  sich 
die  Wiener  Schule  erworben.,  Vgl.  Hohknecht,  Wiener  Klin.  Rundshau,  1905,  Nos. 
16  to  23. 


10  TUMORS    OF    THE    ABDOMINAL    VISCERA 

It  is  well  known  that  gall-stones  can  be  demonstrated  with  a  degree 
of  certainty  in  only  a  small  percentage  of  cases. 

PSEUDO-MALIGNANT  ABDOMINAL   DISEASES 

When  in  connection  with  the  triad  of  general  symptoms,  viz.,  pale- 
ness, weakness  and  emaciation,  and  simultaneously  there  occur  abdom- 
inal manifestations,  such  as  digestive  disturbances,  etc.,  one  will  very 
easily  suspect  malignant  disease  even  without  a  demonstrable  tumor. 

Pernicio us    A  n  einia — Senile 
Tuberculosis — .4 ddison  Icterus 

Here  it  will  be  well  to  think  of  pernicious  anemia  and  senile  tuber- 
culosis, more  or  less  of  the  rather  latent  type,  as  well  as  Addison's 
disease,  always  bearing  in  mind  that  neuropathic  individuals  may  become 
greatly  emaciated  under  a  diet  which  is  self-imposed  or  ordered  by  a 
physician.  The  same  is  true  of  jaundiced  individuals  In  whom  the  stasis 
of  bile  need  not  be  due  to  malignancy. 

Not  infrequently  tumor  formations  may  arouse  the  suspicion  of 
malignancy,  nnich  more  so  when  characterized  by  much  hardness.  In 
these  cases  the  greatest  caution  will  have  to  be  exercised,  especially  when 
they  run  their  course  without  the  above-mentioned  trio  of  general 
symptoms. 

Scyhala 

Thus  it  may  often  be  rather  difficult  at  the  first  examination  to 
distinguish  hard,  round  fecal  masses  in  the  region  of  the  sigmoid  flexure 
from  malignant  tumors,  glands,  etc.  These  inspissated,  stony  scybala 
are  not  often  mouldable;  pressure  upon  the  same  is  not  infrequently 
painful.  It  is  never  sufficient  to  rest  content  with  the  mere  knowledge 
of  the  presence  of  scybala.  We  should  inquire  into  the  causes  that 
lead  to  their  formation. 

Thus  I  recall  a  case  in  which  cancer  of  the  stomach  proved  to  be 
the  cause  of  obstipation,  and  another  case  of  a  deaf  and  dumb  patient 
in  whom  witliout  anamnesis  I  was  led  to  think  of  cancer  of  tlie  stomach 
by  remembering  the  first-mentioned  case,  my  suspicion  in  the  latter  being 
verified  at  autopsy. 

Corset   Lohes   of   the  Liver 

Naturally  a  deep-seated  stenosis  will  be  thought  of  (sigmoid  flexure). 
In  female  patients  it  will  be  well  not  to  forget  the  possibility  of  "corset" 
lobes  of  the  liver,  even  when  the  presence  of  a  tumor  in  the  ileocecal 
region  has  been  established.  On  account  of  induration  these  lobes  may 
feel  very  hard  and,  where  a  deep  "corset"  groove  has  resulted,  the  con- 
nection of  such  a  lobe  with  the  liver  may  not  be  easily  made  out. 

Extraordinarily  hard  tumors  may  be  produced  by  the  deposition  of 
lime,  and  which,  at  times,  may  be  mistaken  for  a  malignant  enlargement. 

In  a  case  under  my  own  obsem^ation,  in  which  there  was  left-sided 
hemorrhagic    pleuritic    effusion,   there   was    found   under   the   left    costal 


PSEUDO-MALIGNANT    DISEASES  11 

arch  an  extremely  hard  mass  wliich  I  was  Inclined  to  consider  as  the 
priniar}^  focus.  Autopsy,  however,  disclosed  cancer  of  the  lung.  The 
hard  mass  under  the  costal  arch  on  the  left  side  corresponded  to  the 
anterior  pole  of  the  spleen  displaced  downward,  and  in  the  capsule  of  it 
there  had  formed  a  qiiite  large  calcareous  deposit. 

Stone-hard  consistency  must  always  be  considered  cautiously;  it  is 
such  a  degree  of  hardness  that  malignant  tumors  do  not  attain. 

Tncholtezoar 

When  the  patient  happens  to  be  a  young  woman  with  hysterical 
tendencies,  an  epigastric  enlargement  should  remind  us  of  trichobezoar, 
i.e.,  a  hair  tumor,  which  may  result  from  the  swallowing  of  hair  during 
a  period  of  man}^  years. 

The  possibility  of  mistaking  conditions  like  the  above  for  cancer  is 
proved  by  the  case  of  Bollinger,'*  which  was  accompanied  by  severe 
cachexia  and  in  which  was  found  a  mass  of  hair  weighing  900  g.  The 
appearance  of  hair  in  the  feces,  in  the  vomit  or  in  the  stomach  lavage, 
above  all  an  exact  history  of  chewing  the  hair  braid,  absence  of  occult 
intestinal  hemorrhage,  and  finally  the  incongruity  of  a  tumor  with  an 
otherwise  healthy  general  condition,  will  guard  us  against  mistaking  hair 
tumors  for  malignant  gastric  conditions.  More  frequently  mistaken 
diagnosis  of  floating  kidney,  spleen,  and  tumors  of  the  omentum  appear 
to  have  slipped   in. 

PJifjfohezoar 

Equally  rare  are  tumefactions  of  the  stomach  composed  of  plant 
fibres  (phytobezoar)  which  are  occasionally  observed  after  the  habitual 
use  of  black  root  or  shellac  stones  (due  to  drinking  polish). 

Suhmticous  Lipomata 

Lipomata  of  the  colon  are  extremely  rare ;  much  more  so  are  fatty 
tumors  which  reach  the  size  of  a  man's  fist,  developing  in  the  submucosa 
of  the  stomach.  They  may  lead  to  threatening  manifestations  by  invag- 
ination, and  also  provoke  colic  and  other  bowel  disturbances  such  as 
obstipation,  diarrhea,  meteorism,  etc.  Circumstances  of  this  kind  may 
excite  suspicion  of  a  malignant  growth  when  a  tumor  is  palpable.  How- 
ever, the  absence  of  cachexia  and  emaciation  will  be  important  factors. 

Nelaton  Tumors 

In  the  differential  diagnosis  of  malignant  abdominal  tumors  we  may 
occasionally  have  to  deal  with  those  growths  known  as  "^Nelaton  tumors," 
which  seem  to  occur  especially  in  females  between  twenty  and  thirty  years 
of  age,  though  they  are  but  very  rarely  seen. 

Being  fibromata  or  fibro-sarcomata  they  are  characterized  by  a  tough 
consistence,  and  eventually  also  knobby  excrescences,  two  important 
characteristics  of  malignant  neoplasms.  If  they  are  located  in  the  deep 
pre-perltoneal  layers  of  the  belly-wall,  they  act  just  like  intra-abdominal 
tumors  in  that  they  disappear  upon  contraction  of  the  abdominal  muscles. 

'Bollinger,  Miinchener  mcd.   Wochenschr.,   1891,   No.  22. 


1^  TUMORS    OF    THE    ABDOMINAL    VISCERA 

CASE  from  my  own  observation:  F.  N.,  24  years  of  age,  female. 
The  patient  has  for  six  months  been  complaining  of  pains  to  the  left 
of  the  umbilicus,  where  there  is  a  palpable  tumor ;  pains  occur  one  hour 
after  eating.  During  two  months  the  quantity  of  urine  has  been  dimin- 
ished, the  color  darker.  On  the  left  side,  underneath  the  costal  arch, 
there  is  a  hard  and  irregular  tumor-mass,  which  is  tender  on  pressure, 
and  disappears  when  the  patient  sits  up. 

In  view  of  the  misleading  subjective  symptoms  the  following  possi- 
bilities presented  themselves,  whether  looked  at  from  the  medical  or 
surgical  point  of  view:  Cicatrized  ulcer,  kidney  tumor,  enlarged  glands, 
carcinoma  of  flexura  lienalis  of  the  colon. 

The  operation  disclosed  a  ^'Nelaton  tumor"  behind  the  abdominal 
muscles. 

The  above  case  illustrates  very  well  iiow  misleading  such  a  tumor 
of  the  belly-walls  may  be. 

In  these  cases,  again,  it  will  be  well  to  include  the  absence  of  cachexia 
as  an  important  factor  in  our  calculations. 

Such  a  decision  as  to  the  malignant  origin  of  a  palpable  mass  in 
the  abdomen  is  so  far-reaching  in  its  consequences  that  we  should  always 
carefully  consider  the  possibility  of  an   inflammatory  exudative  process. 

It  is  an  easy  diagnostic  rule  to  think  of  tuberculosis  and  actinomy- 
cosis in  tumors  of  the  ileocecal  region,  if  they  are  hard,  slightly  painful, 
and  accompanied  by  moderate  temperature  rise.  Regard  must  also  be 
had  to  masses  of  exudate  due  to  appendicitis,  which  sometimes,  espe- 
cially in  their  later  stages,  may  i)e  very  hard.  If  in  these  cases  of 
delayed  resolution  the  patient  happens  to  be  advanced  in  years — and 
this  apparently  is  not  seldom  the  case — the  suspicion  of  malignancy  is 
often  well  founded.  Only  the  most  exact  histor\^  (sudden  febrile  begin- 
ning when  the  patient  has  been  enjoying  the  best  of  health)  can  guard 
against  errors.  Moreover,  the  possibility  of  a  secondary  paracolitic 
abscess  resulting  from  cancer  of  the  cecum  must  be  borne  in  mind,  espe- 
cially after  prodromal  cachectic  symptoms. 

Gland   Tuberculosis   in    the   Abdomen 

Tuberculous  processes  in  the  epigastrium  are  met  with  much  more 
rarely  than  in  the  ileocecal  region;  but  even  there,  under  certain  cir- 
cumstances, may  lead  to  enlargements  from  omental  tuberculosis,  sup- 
puration of  glands  with  the  formation  of  cold  abscesses,  etc. 

F.  S.,  65  years  of  age,  widow.  Had  nine  children ;  had  transitory 
hemoptysis,  violent  cough  and  great  weakness.  Began  about  one  and 
one-half  years  ago,  January,  1903,  by  feeling  weak,  very  sleepy  toward 
evening. 

In  April,  1904,  had  sudden  and  severe  stomach  cramps  which  lasted 
through  the  entire  night.  Since  then,  during  the  last  two  months,  there 
is  cough  with  rather  copious  expectoration,  accompanied  by  pain  under- 
neath the  costal  arches.  Lost  6  kg  in  weight  since  the  winter  of  1903- 
1904. 

Status  presens:  June  7,  1904  (Clinic  Xeusser),  mass  under  the  costal 


PSEUDO-MALIGNANT    DISEASES  13 

arcli  on  tlie  left  side  which  in  extent  and  configuration  is  similar  to  the 
spleen,  if  same  could  be  thought  of  as  extending  to  the  umbilicus.  This 
tumor  is  quite  hard,  without  tenderness  on  pressure,  easily  shaken  by 
pulsation.  Over  the  central  portion  of  the  tumor,  as  well  as  in  Traube's 
space,  there  is  dulness  on  percussion. 

Infiltration  of  the  apex  of  the  right  lung.     Edema  over  the  sacrum. 

Temperature  of  39.4°  C.  on  one  day  only,  otherwise  afebrile. 

Blood:  3,900,000  erythrocytes,  G0%  hemoglobin;  14,600  leucocytes. 

Urine:  slightly  diazo  reaction. 

Stomach:  After  a  test-breakfast  of  a  roll  and  tea  there  was  no  free 
HCl. 

Result  of  operation  (Clinic  Hochenegg,  Docent  Dr.  Alhrecht)  :  The 
spleen-like  tumor  in  the  epigastrium  extensively  adherent  to  the  belly- wall. 
Also  adhesions  to  the  small  intestines. 

Puncture:  yellowish  green,  thin  pus  (cold  abscess!). 

Liver  Gumma 

In  the  case  of  an  apparently  malignant  tumor  of  the  liver  there  is 
always  the  question  of  a  gunmia,  and  accordingly  a  Wassermann  test 
is  in  order. 

Tumors    of    Omentum 

Special  attention  should  be  paid  to  those  inflammatory  omental  tu- 
mors which  are  observed  particularly  after  partial  resection  of  the 
omentum  (herniotomy),  and  also  after  pelvic  peritonitis.  If  the  follow- 
ing symptoms  appear  within  a  few  weeks  after  section  of  the  omentum, 
as  most  frequently  happens — severe  local  pains,  signs  of  peritoneal  irri- 
tation, occasional  signs  of  intestinal  stenosis,  moderate  rises  in  tempera- 
ture, and  above  all  the  enlargement — there  wall  be  hardly  any  difficulty 
in  the  recognition  of  these  cases. ^'^ 

Far  greater  is  the  danger  of  making  a  mistake  when  the  inflammatory 
omental  swelling  comes  on  spontaneously,  i.e.,  without  surgical  inter- 
ference. 

This,  though  very  seldom,  seems  to  occur  in  those  cases  where  por- 
tions of  the  omentum  remain  in  the  hernial  sac  for  a  long  time,  or  where 
inflammatory  peritoneal  processes  have  taken  place  around  some  of  the 
abdominal   organs    (especially  about  the   female  genitalia). 

A  correct  interpretation  will  be  rendered  difficult  even  then,  when 
the  inflammatory  swelling  of  the  omentum  shows  up  years  after  the 
operation. 

In  this  way  there  may  develop  swellings  up  to  the  size  of  a  child's 
head,  sometimes  in  the  epigastrium,  in  the  median  line  or  to  the  right 
and  in  the  periumbilical  or  lower  abdominal  region — in  short,  without 
any  definite  topography.  In  this  connection  we  find  adhesions  to  the 
belly-wall  among  the  frequent  occurrences. 

^"Compare  Dennii  G.  Zesae  Deutsche  Zeitschr.,  f.  Chir.,  1909,  Vol.  98,  page  503. 


14  TUMORS    OF    THE    ABDOMINAL    VISCERA 


CHEMICAL    PROOF    OF    BLOOD    IX    THE    FECES 

Whenever  there  are  reasons  for  suspecting  the  existence  of  a  malig- 
nant disease  of  the  gastro-intestinal  tract,  the  eventual  finding  of  blood- 
coloring  matter  in  the  feces  will  be  of  great  diagnostic  interest. 

Chemical  analysis  of  the  stomach  contents  (whether  vomited  or  washed 
out)  is  mostly  superfluous,  because  fresh  blood  or  decomposed  blood 
(coffee-groundlike  masses)  can  easily  be  made  out  by  inspection,  and 
preserved,  or  pale  erythrocytes  can  easily  be  distinguished  under  the 
microscope,  as  they  are  often  found  alongside  of  clumps  of  brown  blood 
pigment. 

The  color  peculiar  to  the  feces  is  due  partly  to  the  changed  coloring 
matter  of  the  bile,  partly  to  the  food  taken  in  (blood-coloring  matter 
of  meat  and  plant  pigment),  or  to  medicaments  (bismuth,  iron,  silver, 
hemoglobin  preparations,  etc.)  ;  from  which  it  follows  that  blood  coming 
from  the  upper  segments  cannot  be  demonstrated  microscopically. 

Only  wlien  the  blood  comes  from  tlie  lower  segments  of  the  gut  (anal 
opening,  ampulla  or  sigmoid  flexure)  can  it  be  demonstrated,  as  in  the 
stomach,  macroscopically  or  at  least  microscopically.  In  all  other  cases 
we  must  have  recourse  to  clicmical  analysis." 

Gastro-intestinal  liemorrhages  of  this  kind  (including  liemorrhage 
from  the  esophagus)   are  at  present  often  designated  as  "occult."  ^^ 

It  seems  to  me,  that  with  the  numerous  methods  of  chemical  analysis 
too  little  regard  is  given  to  the  practical  diagnostic  points,  and  yet 
unnecessary  efforts  are  made  to  add  to  the  detail  of  existing  methods. 
Thus  the  fact  is  overlooked  that  the  professional  chemist  aims  at  dis- 
covering the  minimum  trace  of  a  certain  substance,  although  the  diag- 
nostician takes  no  interest  in  such  minimum  traces.     So  also  hei-e. 

That  method  will  jueld  the  most  valuable  results  which  shows  a  clear, 
positive  reaction  when  there  is  question  of  more  than  a  mere  trace  of 
blood-coloring  matter. 

Besides,  it  seems  important  to  me  to  employ  the  same  method  every 
time  and  alwaj^s  in  the  same  manner  in  order  to  gain  data  for  com- 
parison. 

The  van  Deen-Weber  test  is  probably  best  adapted  for  the  purpose, 
but  I  recommend  absolutely  the  use  of  h^'drogen  peroxide  only  as  oxidiz- 
ing agent. 

The  following  are  the  details  of  the  method  as  it  has  been  practised 
in  my  department  for  many  years,  and  which  on  account  of  its  simplicity 
would  seem  to  merit  general  adoption : 

Method  of  Testing  for  Blood 

By  means   of  a  glass   rod  place   a  quantity   of   fecal   matter,   about 

"  Only  very  exceptionally,  where  there  is  very  rapid  passage  through  the  bowels* 
can  erythrocytes,  coming  from  gastric  hemorrhage,  be  demonstrated  in  the  feces,  and 
then   occasionally   the  cells   appear  enlarged   and   glistening  like  wax. 

"  In  my  ojiinion  it  would  be  commendable  to  have  some  regard  for  grammar  and 
simply  speak  of  "chemical"  hemorrhages;  to  call  something  "occult"  when  it  can  be 
clearly   demonstrated    at   anv    time,   does   not   seem    rational. 


BLOOD    IN    THE    FECES  15 

the  size  of  a  hazel-nut,  upon  the  bottom  of  a  test-tube  and  add  an 
approximately  equal  volume  of  glacial  acetic  acid.  Thoroughly  mix  the 
feces  and  the  glacial  acetic  acid  by  stirring  with  the  glass  rod,  this 
being  done  in  order  to  provide  access  for  the  acetic  acid  to  the  blood- 
coloring  material  and  to  effect  its  change  into  acid  hematin. 

Then,  in  order  to  dissolve  the  acid  hematin  which  has  formed,  add 
2  to  3  ccm  alcohol  ^^  and  stir  again  with  the  glass  rod.  In  another  test- 
tube  place  an  equal  quantity  of  guaiac-resin,  finely  powdered,  and  pour 
over  it  1  to  2  ccm  alcohol,  shaking  this  mixture  until  a  saturated  solution 
has  been  obtained,  when  there  will  remain  some  undissolved  guaiac-resin. 
Decant  the  upper  portion  of  the  saturated  solution  (the  undissolved 
portion  of  the  guaiac  remaining  behind)  into  the  first  testing  glass  ^^ 
and  add  a  little  hydrogen  peroxide.  In  the  presence  of  a  large  amount 
of  blood  there  immediately  appears  a  deep  dark  blue  color.  When 
smaller  quantities  of  blood  are  present  the  color  may  be  only  dark 
green;  upon  the  addition  of  a  little  water  and  some  chloroform  (about 
as  much  as  the  top  of  the  test-tube  will  hold)  the  chloroform  will  assume 
a  violet  to  blue  color  from  the  coloring  matter  that  has  formed.  It  is 
always  advisable  to  repeat  the  test  after  about  two  minutes  as  a  control, 
because  a  positive  reaction,  as  shown  by  the  blue  color,  may  be  more 
clearly  observed. 

If  the  Weber  test  is  carried  out  in  this  way  it  will  hardly  take  more 
than  a  minute,  requires  only  two  test-tubes  and  one  glass  rod,  wherefore 
it  is  particularly  adapted  for  use  during  office  hours. 

This,  however,  is  of  the  greatest  importance,  for  an  early  diagnosis 
of  gastric  or  intestinal  cancer  rests  largely  in  the  hands  of  the  practical 
physician.  When  the  chemical  examination  for  blood-coloring  matter 
in  the  feces  proves  positive,  the  following  questions  Avill  suggest  them- 
selves : 

"AUmentarii"  Melena 

1.  May  not  tlie  blood-coloring  matter  come  from  meat  taken  in  as 
food  ^•'  or  from  medicines  containing  hemoglobin  (puro,  hemotogen, 
etc.).^ 

If  a  positive  blood  reaction  in  the  feces  is  to  be  of  any  diagnostic 
value  it  will  be  necessary  that  the  patient  take  into  his  stomach  no  kind 
of  blood-coloring  material  for  three  days.  The  use  of  meat  and  sausage 
is  to  be  forbidden ;  other  restrictions  in  diet,  however,  are  not  insisted 
upon. 

Microscopic  control  should  always  be  made  of  the  fecal  matter  which 

"Ether  may  be  used  as  well;  but  I  have  always  observed  a  perfect  parallelism 
in  the  result  of  reaction,  whether  alcohol  was  used  or  ether.  T  prefer  alcohol,  because 
it  seems  to  extract  more  rajiidly.  1  consider  the  objections  made  in  the  literature  to 
the  use  of  alcohol   as  being  entirely   without   foundation. 

"Whoever  desires  may  pour  off  the  alcohol  or  ether  layer  into  another  test-tube 
and  use  it  for  the  test.  I  do  not  consider  it  necessary,  in  fact  there  is  a  possi- 
bility of  losing  blood   coloring  matter  that  has  not   yet  been   extracted. 

"  Ham,  sausages,  and  bloody  meats  are  especially  to  be  considered,  as  they  may 
cause  a  positive  reaction   as  late  as  the  third  day  after  their  elimination   from  diet. 


16  TUMORS    OF    THE    ABDOMINAL    VISCERA 

has  been  used  for  the  blood  test  so  as  to  discover  possible  muscle  fibres. ^^ 
With  sluggish  intestinal  function  it  may  be  possible  to  find  such  muscle 
fibres  as  late  as  the  third  day  after  the  discontinuance  of  a  meat  diet. 
In  such  cases  it  may  be  desirable  at  the  outset  to  administer  a  light  laxa- 
tive (e.g.,  pulv.  rad.  rhei)  in  order  to  remove  any  accumulations  of 
fecal  material. 

This  microscopical  examination  will  be  of  value  also  in  so  far  as  it 
may  reveal  clumpy,  dark  brown  blood  pigment,  packed  together,  due 
to  hemorrliages  higher  up  in  the  gut,  in  this  way  confirming  the  chemical 
findings. 

Microscopic  demonstration  of  blood  pigment  is  made  easier  and  diag- 
iiostically  more  valuable  in  tliose  cases  where  the  diet  consists  of  milk, 
excluding  all  pigment. 

Origin   of  Hemorrhage 

2.  If  the  first  question  be  answered  in  the  negative,  there  arises  the 
second  (juestion  as  to  the  origin  of  the  hemorrhage. 

Theoretically  there  is  a  great  variety  of  possibilities,  but  as  a  rule 
there  is  a  definite  symptom-complex  wliich  will  favor  localization. 

Nose — Gums 

Accidents,  such  as  hemorrhage  from  the  nose  or  from  the  gums,  are 
ruled  out  by  the  fact  that  a  single  examination  is  never  deemed  sufficient, 
the  feces  being  repeatedlv  tested  for  blood  during  a  considerable  period. 

Sputum 

The  same  holds  good  of  hemorrhagic  sputuiii  that  may  have  been 
swallowed. 

Beclal  Mucosa 

Hemorrhage  from  piles  will  probably  be  visible  to  the  naked  eye  in 
most  instances.  Should  the  stools  be  solid  and  coated  with  bloody  mucus, 
the  chemical  analysis  could,  in  cases  of  suspected  gastric  hemorrhage, 
be  performed  with  portions  taken  from  the  centre  of  the  fecal  mass  with 
the  help  of  two  teasing  needles. 

In  obscure  cases  the  condition  of  the  rectal  nmcous  membrane  may 
be  worthy  of  attention.  Just  as  there  are  individuals  with  easily  bleeding 
gums,  so  also  the  rectal  mucosa  may  occasionally  display  hemorrhagic 
tendency,  of  which  fact  one  can  easily  be  convinced  during  a  rectoscopic 
examination  by  lightly  touching  the  mucosa  with  a  sound  covered  with 
cotton. 

Parenchymatous  bleeding  from  the  gastric  mucosa  also  deserves  full 
consideration. 

Gastric  Crises 

We  may  here  leave   out   of  consideration   those   certainly  extremely 

'"  If  the  patient  is  told  that  disobedience  in  regard  to  prescribed  diet  will  lead 
to  a  mistaken  result  and  therefore  to  "wrong  treatment,"  the  regulations  in  regard 
to  diet  will  probably  be  observed;  still  the  microscopic  control  must  be  made. 


BLOOD    IN    THE    FECES  IT 

rare  cases  of  gastrostaxis  in  wliicli,  without  anatomical  basis,  there  may 
occur  the  severest  hematemesis  and  mclena. 

Much  more  important  are  those  cases  in  whicli  the  vomiting  of  coffee- 
gi-ound  material  may  take  place  as  the  result  of  extreme  and  persistent 
vomiting  attacks,  such  as  occur  in  gastric  crises.  If  the  patient  is  first 
seen  after  the  attack,  the  chemical  demonstration  of  blood  in  the  feces 
might  lead  one  to  think  of  an  ulcerative  process  in  the  stomach. 

La  cage 

In  like  manner  caution  must  be  exercised  in  judging  of  chemical 
blood  findings  in  the  feces  immediately  after  stomach  lavage,  as  in  these 
cases  there  is  a  possibility  of  gastric  hemorrhage  due  to  spasmodic  con- 
traction during  vomiting  or  to  the  stomach-tube  itself. 

Cicalricial  Pyloric  Stenosis 

P^ven  with  benignant  cicatricial  pyloric  stenosis,  parenchymatous 
bleeding  from  the  gastric  mucosa  may  take  place,  and  thus  lead  to  blood 
in  the  feces.  One  may  be  inclined  to  assume  severe  hyperemia  as  the 
cause,  resulting  from  irritation  due  to  disintegrated  stomach  contents 
in  the  presence  of  venous  stasis,  since  the  high  intra-gastric  pressure  can 
easily  effect  compression  of  the  intra-  and  epigastric  venous  plexuses. 

Boirel   Stenosis   and   Acute   Peritonitis 

This  might  also  explain  the  coffee-ground  vomiting,  accompanied  by 
high  degrees  of  meteorism  occasionally  observable  in  cases  of  deep-seated 
stenoses  of  the  intestines,  which  we  also  observe  in  diffuse  acute  peri- 
tonitis. 

Hemorriiagic  Diathesis 

Parenchymatous  bleeding  from  the  gastro-intestinal  tract  may  also 
be  due  to  a  general  hemorrhagic  diathesis  resulting  from  unknown  in- 
juries or  from  sepsis,  severe  icterus,^"  etc.  The  bleeding  may  also  be 
due  to  extreme  portal  congestion,  cancer  of  the  liver,  thrombosis  in  the 
portal  veins,  etc. 

Terminal    Findings 

Terminal  and  preterminal  findings,  therefore,  will  have  to  be  utilized 
with  the  utmost  caution. 

Thus  in  the  late  stages  of  cancer  of  the  pancreas,  gall-bladder,  etc., 
it  may  be  possible  to  discover  blood  in  the  feces  because  of  invasion  of  the 
duodenum,  portal  congestion,  or  as  a  result  of  hemorrhagic  diathesis. 
If,  therefore,  theoretically  our  calculations  were  based,  in  a  one-sided 
way,  upon  a  positive  blood  reaction  in  the  feces,  there  would  be  a  large 
number  of  diagnostic  possibilities,  especially  with  the  existence  of  paren- 
chymatous gastro-intestinal  hemorrhages. 

Practically,  however,  conditions  are,  as  a  rule,  much  more  simple. 

Through   the   mass    of   clinical   symptoms    the   possibilities    are    nar- 

^'  With  pronounced  icterus  the  absence  of  uroi)ilinogen  in  the  stools  seems  also 
to  make  the  demonstration  of  small  quantities  of  blood  not  depending  on  ulceration 
easier,  so  that  the  greatest  cantion   is  here  to  be  observed. 


18  TUMORS    OF    THE    ABDOMINAL    VISCERA 

rowed  down  very  much,  so  that  stomach  aihiaents  which  may  be  sus- 
pected of  carcinoma  mostly  require  differentiation  from  gastric  neurosis, 
constitutional  "achylia,"  peptic  ulcer  or  chronic  gastritis. 

Within  these  narrow  limitations  the  chemical  finding  of  blood  in  the 
feces  is,  in  and  of  itself,  highly  significant. 

Whenever  we  are  confronted  with  the  above  limited  possibilities  for 
differential  diagnosis  and  continual  blood-tests  of  the  feces  turn  out  to 
be  constantly  or  repeatedly  positive,  we  must  always  think  of  some  ulcera- 
tive process,  and  may,  therefore,  eliminate  gastric  neurosis,  achylia  and 
chronic  gastritis.  In  view  of  the  clinical  similarity  between  some  cases 
of  esophageal  cancer  (with  absence  of  difficult  swallowing)  and  cancer  of 
the  stomach  it  would  be  well  not  to  forget  this  possibility. 

In  what  quantity  and  Avith  what  frequency  a  given  case  of  carcinoma 
of  the  stomach  contributes  to  the  admixture  of  blood  in  the  feces  de- 
pends in  part  upon  the  anatomical  character  of  the  tumor. 

The  softer  the  cancer,  the  more  it  inclines  toward  disintegration,  the 
easier  it  may  lead  to  severe  protracted  hemorrhages,  in  this  way  yield- 
ing permanent  positive  blood-tests  in  the  feces.  When  the  carcinoma  is 
of  a  fibrous  character,  severe  hemorrhages  may  often  be  absent  for  many 
days. 

Burdensome   Tests 

In  these  cases  (as  well  as  those  of  benignant  ulcerations  which  do  not 
bleed)  it  may  be  important  to  use  proper  precautions  in  employing  bur- 
densome tests  (Belastungsproben).  As  such  I  consider  the  administration 
of  mechanically  irritating  coarse  brown  bread,  hot  fluids,  physical  exer- 
cise, harsh  palpation,  occasional!}'  also  moderate  inflation  of  the  stom- 
ach by  means  of  effervescent  mixtures.  If,  despite  all  this,  the  chemical 
test  of  the  feces  proves  constantly  negative,  the  possibility  of  an  ulcera- 
tive process  may  be  excluded  from  our  differential  diagnostic  calcula- 
tions as  highly  improbable.  But  the  reverse  may  also  afford  diagnostic 
elucidation. 

Arrest  of  Hemorrhage 

When  during  the  treatment  of  gastric  ulcer  (rest  in  bed,  milk  diet, 
etc.)  where  we  strive  to  prevent  all  mechanical  and  chemical  irritation  of 
the  stomach,  the  blood  disappears  rapidly  from  the  feces  ^^  and  does  not 
recur  even  with  overloading  of  the  stomach,  malignant  ulceration  will  be 
highly  improbable. 

Gastric  Melena  withovt  Blood  in 
the   Stomach    Contents 

The  significance  of  the  chemical  blood  demonstration  in  the  feces,  so 
far  as  gastric  ulcerations  are  concerned,  gains  in  importance  through 
the  fact  that  lavage  of  the  stomach  may  bring  to  light  gastric  contents 
that  do  not  contain  blood,  whereas  examination  of  the  feces  will  yield 
a  positive  result.     We  are  probably  dealing  with  hemorrhages  which  oc- 

"  Even  with  abundant  hemorrhages  from  benign  gastric  ulcer  the  blood-test  in 
the  feces  is  occasionally  negative  after  one  week. 


BLOOD    IN    THE    F?:CES  19 

curred,  for  example,  the  day  previous  or  which,  occurring  in  small  amounts 
and  at  short  intervals,  show  up  in  the  feces  through  summation  accord- 
ing to  the  principle  "gutta  cavat  saxum." 

Good  motilit}^  of  the  stomach,  as  may  occasionally  exist  even  in  cases 
of  cancer  of  the  stomach,  favors  the  flow  of  blood  downward. 

Intestinal  Diseases 

The  considerations  detailed  above  permit  us  to  proceed  to  those  cases 
in  which  diseases  of  the  intestine  require  differential  diagnosis.  Here, 
also,  we  may  generally  say  that  repeated  positive  blood  findings  in  the 
feces  argue  against  a  simple  catarrhal  condition,  and  with  otherwise 
corresponding  symptoms  speak  for  an  ulcerative  disease  of  the  bowel. 
Besides  carcinoma  of  the  large  bowel  there  are  practically  only  two 
other  ulcerative  processes  that  will  have  to  be  considered  most  fre- 
quently, viz.,  tubercular  ulcerations  and  duodenal  ulcer. 

In  this  matter  of  chemical  blood  analysis  in  the  feces  every  man  will 
have  to  gather  his  own  experiences  with  a  constant  method,  in  this  way 
securing  an  important  diagnostic  aid,  especially  in  the  diagnosis  of  gas- 
tro-intestinal  carcinoma. 

It  seems  to  me  of  little  value  to  collect  positive  and  negative  findings 
from  the  literature,  for,  as  already  stated,  the  particular  method  of 
analysis  must  be  taken  into  account. 

Whoever,  for  example,  utilizes  large  amounts  of  feces  to  obtain  blood 
coloring  matter  will  have  positive  results  oftener  than  he,  as  I  recom- 
mend it,  who  carries  out  the  test  in  a  coarser  way.  To  search  for  the 
smallest  traces  of  blood  is  senseless  and  to  no  purpose. 

Recapitulation 

In  conclusion,  it  may  be  well  to  repeat  some  of  the  most  important 
points  of  the  foregoing  considerations. 

1.  Feces  containing  admixtures  of  blood  or  pus  which  can  be  recog- 
nized macroscopically,  or  in  which  muscle  fibres  are  demonstrable  micro- 
scopically are  not  adapted  for  chemical  blood  tests,  since  a  positive  result 
is  generally  not  of  diagnostic  value. ^^ 

2.  If  the  examination  of  feces  for  blood  coloring  matter  is  to  be  of 
diagnostic  value,  it  will  be  commendable  wlfen  obstipation  exists,  to  re- 
move the  old  stools  by  means  of  a  mild  laxative  (e.g.,  pulv.  rad.  rhei) 
or  very  careful  enemata  (avoiding  injury),  and  to  enjoin  a  meat-free 
diet  for  three  days.  Positive  blood  findings  on  the  first  or  second  day 
are  to  be  utilized  with  caution.  Negative  findings  are  not,  of  course, 
significant. 

3.  When  the  blood  findings  are  negative  and  suspicious  clinical  signs 
point  to  an  ulcerative  gastro-intestinal  process,  we  may  proceed  to  make 
"Belastungsproben"  (use  of  bran  bread,  light  gymnastics,  etc.).  When 
the  stools  are  of  a  firm  consistence,  with  blood  on  the  surface  only,  cen- 

"  Clear  pus  yields  exquisitely  positive  van  Deen  reaction.  A  positive  result  of 
reaction  in  stools  containing  pus  would  not,  for  that  matter,  lead  to  error,  since 
purulent  admixtures  occur  exclusively  in  cases  of  perforation  or  ulcerative  processes, 
hemorrhages  usually  occurring  with   such  conditions. 


20  TUMORS    OF    THE    ABDOMINAL    VISCERA 

tral  portions  should  be  utilized.  An  expert  will  occasionally  be  able  to 
determine  whether  the  degree  of  a  positive  blood  reaction  corresponds  to 
the  number  of  muscle  fibres,  but  on  this  point  great  caution  is  in  order, 

4.  In  case  of  positive  blood  findings  we  must  determine  whether,  with 
bland  diet  and  rest  in  bed,  the  blood  does  not  disappear  very  soon  from 
the  feces,  since  in  the  differential  diagnosis  of  benignant  and  malignant 
gastric  ulceration  we  may  decide  to  assume  the  former  condition. 

5.  Even  with  negative  findings  in  the  stomach  contents,  obtained  by 
lavage,  blood  in  the  feces  may  be  of  gastric  origin. 

THE    DIAGNOSTIC    SIGNIFICANCE    OF    VEGETABLE    AND 

BACTERIAL    ORGANISMS    OF    THE    GASTRO-INTES- 

TINAL    TRACT 

In  cases  in  which  there  is  suspicion  of  malignant  disease  in  the  gas- 
tro-intestinal  tract,  the  microscopical  examination  of  the  stomach  and 
bowel  contents  should  not  be  made  without  considering  in  their  general 
aspect  vegetations  that  ma}'  be  present.  In  this  way  we  not  rarely  ob- 
tain symptoms  which  are  of  especial  significance  as  a  foundation  for  the 
final  diagnosis,  since  they  make  its  limitations  comparatively  narrow. 

The  diagnostic  value  of  a  symptom,  however,  is  inversely  propor- 
tionate to  the  scope  of  its  limitations. 

A  concrete  example.  The  demonstration  of  an  abundant  "lactic- 
acid  bacilli"  vegetation  in  the  feces  possesses  an  incomparably  higher 
value  than  the  demonstration  of  an  achlorhydria,  because  the  latter 
symptom,  in  its  causative  interpretation,  affords  room  for  dispropor- 
tionately more  possibilities. 

It  does  not  seem  useless  to  me  to  emphasize  that  there  exists  a  vast 
difference  between  the  diagnostic  value  of  saprophytic  and  infectious 
germs,  which  difference  is  based  partly  upon  the  fact  that  the  former  are 
effect,  the  latter  cause. 

Whilst,  under  certain  circumstances,  infectious  germs  are  of  much 
significance  even  when  occurring  singly,  saprophytic  organisms  are  of 
value  only  when  present  in  numbers.  Only  their  abundant  occurrence 
excludes  the  possibility  of  accidental  presence  and  proves  that  certain 
conditions  for  their  favorable  growth  were  present  at  the  site  of  their 
development. 

From  this  there  follow  certain  deductions  for  the  diagnostic  valua- 
tion of  saprophytic  findings. 

1.  It  is  apparent  that  it  remains  a  matter  of  personal  experience  to 
know  the  limitations  within  which  the  occasional  discovery  permits  of 
diagnostic  acceptance. 

2.  The  demonstration  of  a  certain  saprophyte  by  culture  can  never 
be  a  question  of  prime  import,  hence  there  is  no  sense  in  culture  methods. 

The  weight  of  the  diagnosis  rests  much  more  upon  the  unstained  or 
dry  cover-glass  preparation,  as  it  alone  enables  us  to  make  an  exact 
estimate  as  to  the  deciding  quantitative  conditions. 

Theoretically,  an  immediate  examination  of  stomach  and  bowel  con- 


VEGETABLE  AND  BACTERIAL  ORGANISMS     21 

tents  would  be  required  in  order  to  exclude  subsequent  increase  of  sa- 
prophytic germs.  But  in  so  far  as  "lactic-acid  bacilli"  and  "sarcina  ven- 
triculi  Goodsir^''  arc  concerned,  such  apprehensions  are  out  of  place, 
since  their  multiplication  within  a  few  hours  outside  of  the  body  and  at 
room  temperature  need  not  be  taken  into  consideration. 

3.  Since  only  quantitative  conditions  decide,  special  precautions  are 
not  necessary  in  obtaining  the  material  for  examination. 

Gastric  Vegetations  appearing 
in  the  Feces 

Even  in  those  cases  when  clinical  signs  point  to  a  malignant  disease 
of  the  stomach  it  will  be  advisable  to  examine  the  feces  providing  there 
are  no  vomited  stomach  contents  at  hand.  For  as  far  as  sarcina  ven- 
triculi  Goochir,  or  an  abundant  growth  of  lactic-acid  bacilli  are  con- 
cerned, the  conclusions  are  nearly  identical  whether  the  findings  have 
been  made  in  the  stomach  contents  or  in  the  feces. 

The  examination  of  the  feces  for  gastric  vegetations  is  of  importance 
for  another  reason. 

I  have  observed  cases  of  gastric  cancer  in  which  on  certain  days  the 
stomach  contents  revealed  an  extraordinarily  abundant  vegetation  of  lac- 
tic-acid bacilli,  whereas  on  other  days  the  findings  were  hardly  sufficient 
to  be  of  diagnostic  value ;  the  findings  in  the  stools,  however,  remained 
constant.  shoM'ing  abundant  growth  of  lactic-acid  bacilli. 

On  the  other  hand,  there  may  be  cases  in  which,  under  the  influence 
of  a  cancer  that  is  developing  upon  the  site  of  a  cicatrix,  the  sarcina? 
vegetations  disappear  from  the  stomach,  to  be  replaced  by  a  growth  of 
lactic-acid  bacilli,  in  which  cases  the  last  "stragglers"  of  the  sarcinas  maj^ 
still  be  found  in  the  feces. 

Fresli  Preparation 

For  practical  diagnostic  purposes  examination  of  the  fresh  prepara- 
tion is  to  be  recommended  most.  A  small  drop  of  Lugol's  solution  is 
placed  upon  the  slide  and  as  small  a  quantity  of  feces  or  stomach  con- 
tents is  stirred  into  it  by  means  of  platinum  loop  or  needle.  An  effort 
should  alwaj's  be  made  to  obtain  a  floating  portion  of  feces,  as  this  adds 
to  the  ease  of  observation. 

A  very  good  view  is  also  obtained  in  the  thin  portions  of  the  border 
of  a  hanging  drop.  The  Lugol  solution  will  stain  not  only  food  rem- 
nants like  starch,  muscle  fibres  (through  imbibition  with  bilirubin  green 
coloring),  but  also  imparts  color  to  saprophytic  germs  such  as  clostria?, 
leptothrix  varieties,  and  "large-celled"  sarcinae. 

The  experienced  observer  will  often  be  able  to  content  himself  with 
looking  over  the  fresh  preparation,  since  the  morphological  details  are, 
as  a  rule,  entirely  sufficient. 

Where  time  will  permit  or  with  insufficient  experience  in  this  domain, 
it  is  advisable  to  make  Gram  stained  dry  preparations,  at  least  in  so  far 
as  rod-shaped  bacilli,  cocci  or  spirochetes  are  diagnostically  concerned. 
Take  a  loopful  of  stomach  contents  or  feces  and  smear  it  over  a  cover- 


22  TUMORS    OF    THE    ABDOMINAL    VISCERA 

glass,  avoiding  a  smear  that  is  too  thick,  dry  it  in  the  air  and  fix  it  by 
passing  it  through  the  flame  three  times ;  then  stain  according  to  Gram. 
Only  the  micro-organisms  become  fixed,  as  the  foodstuffs,  because  of  their 
greater  size,  are  carried  away  during  washing.""^  This,  however,  affords 
an  excellent  view  of  the  growths  fhat  may  be  present. 

Only  very  exceptionally  does  it  become  necessary — at  least  for  the 
experienced  observer — to  make  a  plate  culture.  This  might  enter  into 
consideration  when  the  feces  contain  numerous  Gram-positive  rod-shaped 
bacilli  and  there  is  a  doubt  whether  we  are  dealing  with  lactic-acid  bacilli. 
Even  here  special  propagative  measures,  culture  methods,  etc.,  are  prac- 
tically quite  superfluous.  For,  if  it  be  question  of  a  scant  number  of 
lactic-acid  bacilli,  they  have  no  diagnostic  sigiiiflcance,  but  if  they  are 
present  in  large  numbers,  they  will  without  difficulty  thrive  on  2%  grape- 
sugar  agar. 

In  the  cultivation  of  stomach  and  bowel  contents  I  always  reconmiend 
the  streak  procedure  by  means  of  a  platinum  spatula,  because  in  this 
way  we  can  succeed  in  immediately  recognizing  contaminations  from  the 
air,  especially  air  sarcina*,  by  their  topographical  position  between  the 
streaks. 

With  stomach  contents  it  will  be  possible  to  bring  the  platinum  spat- 
ula in  direct  contact  before  making  the  streak,  but  for  culture  from 
feces  it  is  advisable  to  float  one  to  three  loopfuls  in  a  bouillon  tube,  then 
immerse  the  spatula,  remove  excess  by  swinging  and  proceed  to  make  the 
streak;  without  this  precautionary  measure  confluent  areas  of  colon  ba- 
cilli are  obtained,  which  renders  it  almost  impossible  to  discover  isolated 
colonies  of  lactic-acid  bacilli. 

It  will  now  be  in  place  to  briefly  discuss  the  different  findings  in  the 
gastro-intestinal  bacterial  and  vegetable  growths  in  so  far  as  the  interest 
of  clinical  diagnosis  requires  it. 

A.    Lactic- A  rid  BaciUi 
Synonyms:  Boas-Oppler  B.,  "long''  B.,   B.""    lilifornis.   B..   jjeniculatus   de    Bary. 

In  a  work  published  in  1886*  from  KnssmauVs  clinic,  Dc  Bart/  '-  has 
described,  among  others,  cases  of  cancer  of  the  stomach  in  wliich  the 
,  stomach  contents  contained  great  numbers  of  long  and  short  rod-shapes 
which  were  immotile.  Their  length  varied  from  4  to  20  [^..  In  ap- 
pearance the  bacillus  resembled  that  of  anthrax.  The  number  of  rod- 
shapes  showing  up  in  the  microscopic  field  was  enormously  large ;  every- 
thing else  stepping  into  the  background  (page  253). 

There  is  not  the  least  doubt  that  in  this  case  De  Bary  had  under  the 

'"The  same  fate  may  at  times  easily  befall  sarcinae  that  are  present;  wherefore, 
as  already  emphasized,  the  examination  of  the  fresh  preparation  is  absolutely  neces- 
sary to  determine   the  presence  of  this   saprophyte. 

''  An  inappropriate  designation.  The  length  varies  from  cocci-like  rods  (dwarf 
forms)  to  long  threads  (giant  forms).  The  width  is  more  constant;  they  are  always 
"thin"    bacilli. 

^^  Dp  Barif.  Beitrag  zur  Kenntniss  der  niederen  Organismen  im  Mageninhalte. 
Arch.  f.   Experim.  Pathol,   ii.  Pharm.,  1886,  XX. 


VEGETABLE  A\U  BACTERIAL  ORGANISMS     23 

microscope  an  abundant  pure  culture  of  lactic-iicid  l)acilli.  However, 
with  his  method  of  cultivation  on  nutritive  media  that  were  fluid  and  did 
not  contain  sugar  Hie  lactic-acid  bacillus  could  not  tiu-ive  and  l)e  Bury 
confused  a  "Subtilisart"  in  an  abundant  superficial  mould  with  the  lac- 
tic-acid bacilli  seen  in  the  fresh  preparation. 

Later  on,  Boas  (1892)  and  Oppler  (1895)  again  called  attention 
to  the  occurrence  of  an  abundant  vegetation  of  rod-shaped  bacilli  in  the 
stomach  contents  in  cases  of  gtistric  carcinoma,  without  obtaining  a 
culture. 

ir.  Schlesinger  and  Kaufman  -^  were  the  first  to  carry  out  the  plate 
cultures  of  the  rod-shaped  bacilli,  which  up  to  this  time  had  been  only 
moi-phologicall}'  characterized,  and  the}^  found  the  important  fact  that 
the  addition  of  2%  grape-sugar  to  ordinary  sugar  brings  about  a  good 
growth  at  incubator  temperature. 

Stenosing  cancers  of  the  pylorus,  accompanied  by  "coffee-ground" 
vomiting,  furnish  the  largest  yield  of  lactic-acid  bacilli  in  the  stomacii 
contents  as  well  as  in  the  feces.-*  One  who  is  not  sufficienth^  familiar 
with  gastro-intestinal  bacterial  growths  would  do  well  to  preserve  speci- 
mens of  the  stomach  contents  and  feces  from  such  "extreme"  cases  for 
purposes  of  comparison  when  making  tests, -"^  in  order  to  recognize 
growths  of  lactic-acid  bacilli  when  these  latter  show'  up  less  clearly. 

Whilst  vegetations  of  rod-shaped  bacilli  in  the  feces  consist  mostly  of 
forms  that  are  short  and  of  equal  length,  we  find  in  the  picture  furnished 
by  a  stool  of  the  above  description  (see  Plate  Fig.  2,)  that  there  are 
considerable  differences  in  the  length  of  the  rod-shaped  bacilli;  they  are 
thin,  occasionally  amounting  to  threads;  their  protoplasm  seems  to  con- 
tain granules  here  and  there,  never  contains  spores ;  the  shorter  bacilli 
often  meet  at  angles. 

The  above-described  picture  occurs  in  isolated  form  in  the  stomach 
contents  ;  in  the  feces  it  appears  as  if  it  had  sprouted. 

By  floating  the  stomach  contents  or  feces  in  Lugol's  solution,  the 
above-described  lactic-acid  bacilli  do  not  show  any  blue  or  violet  stain. 

This  distinguishes  them  from  those  usually  long,  thick,  plump  forms 
of  leptothrix  which,  because  they  cannot  grow  under  aerobic  conditions, 
are  found  in  enormous  quantities  in  the  tartar  about  the  teeth,-"  and 
which  are  occasionally  demonstrable  in  the  feces,  especially  when  the  lat- 
ter are  acid  in  reaction — as  a  separate  type  of  vegetation. 

Tlie  forms  of  leptothrix,  just  referred  to,  take  on — even  though  not 

"^Schlesinger  and  Kaufman.  Uber  einen  Milchsaiirebildenden  Bacillus  \ind  sein 
Vorkommen  im  Magensaft.     Wiener  klin.     Rundschau,  189fi,  Nov.   15. 

"jR.   Schtnidt.     Mitt.   d.   Ges.   f.  innere   Med.    in   Wien.,   1903,   Nov.   5. 

-'With  the  addition  of  a  few  drops  of  forniol  such  sjiecimens  may  be  pre'^erved 
in   glass-stoppered  bottles   for  an   indefinite  period. 

"^  In  the  bacteriological  examination  of  the  tartar  about  the  teeth  we  find,  for  that 
matter,  gradual  transitions  from  the  typical  forms  of  lej>tothrix  that  stain  blue  with 
iodin  to  slender  rod-shaped  forms  which  entirely  resemble  the  lactic-acid  bacillus 
morphologically;  however.  1  have  never  succeeded  in  making  a  culture.  Still  T  con- 
sider it  very  probable  that  this  is  the  parent  form  of  the  lactic-acid  bacillus  which 
has  come  into  its  present  state  through  adoption  of  the  leptothrix  form  of  the  oral 
cavitv  to  the  conditions  in  the  stomach   (mostly  a  cancerous  stomach). 


24  TUMORS    OF    THE    ABDOMINAL    VISCERA 

constantly — a  blue  violet  stain  if  the  Lugol  solution  works  its  way  into 
the  oftentimes  granulated  protoplasm,  but  care  must  be  taken  to  see 
that  the  material  to  be  examined  is  thorouglily  stirred  in  the  drop  of  Lu- 
gol, so  that  the  iodin  solution  actually  comes  into  contact  with  the 
threads  of  leptothrix. 

In  regard  to  Gram  staining,  the  lactic-acid  bacilli  and  forms  of  lep- 
tothrix are  in  perfect  accord,  that  is,  they  are  Gram-positive  except  when 
in  the  case  of  outgrown,  older  and  evidently  degenerate  forms,  the  pro- 
toplasm has  ceased  to  be  partly  or  entirely  alcohol-fast  and  hence  shows 
up,  in  contrast,  color  that  is  Gram-negative. 

Gram-positive  Bacilli  in  the  Feces 

As  far  as  the  Gram  picture  in  the  feces  is  concerned  the  lactic-acid 
bacilli  have  two  doubles,  whose  frequent  presence  lead  to  Gram-positive 
bacilloses  in  the  feces. 

Filiform  Type  with   Granular  Reaction 

1.  Filiform  type  with  granule  reaction.-^  Under  this  term  I  have 
registered  cases  in  which  the  long,  thick.  Gram-positive  forms  of  lepto- 
thrix, just  referred  to,  predominate  in  the  stool. 

This  picture  of  a  vegetation  is  not  frequent.  It  ma}-  occasionally  be 
found  in  "intestinal  fermentative  dyspepsia"  {A.  Schmidt),  hence  in 
evacuations  that  are  acid  in  reaction,  light  yellow  in  color,  soft  in  consis- 
tency, and  have  the  odor  of  butyric  acid;  sometimes  I  have  found  it  in 
intestinal  and  peritoneal  tuberculosis,  never  so  far  in  malignant  processes 
of  the  large  bowel. 

The  differentiating  characteristics  from  the  lactic-acid  bacillus  may 
here  be  summarized  once  more:  throughout  conspicuously  long  plump 
threads,  curled  here  and  there  like  a  whip,  staining  frequently  "with  iodin, 
cannot  be  cultivated  aerobically.  Stomach  contents  contain  no  analogous 
rod-shapes,  but  do  not  infrequently  show  absence  of  HCl  (achylia  gas- 
trica)  when  "intestinal  fermentative  dyspepsia"  is  present. 

"Pseudo-colon"  Type 

2.  "Pseudo-colon"  type.  This  is  a  Gram-positive  bacillosis  in  the 
feces  described  by  me,  being  rod-shaped  bacilli,-'^  Gram-positive,  anaero- 
bic, occurring  in  large  numbers,  and  in  contrast  with  the  colon  bacillus 
stand  out  through  their  more  glistening  appearance. 

Whoever  wishes  to  procure  test  stools  containing  this  ty^e  of  vegeta- 
tion should  be  guided  by  the  description  given  under  1,  of  stools  that  are 
acid,  light  yellow,  having  the  odor  of  butyric  acid,  often  foamy,  which, 
according  to  my  experience,  occur  most  frequently — though  seldom — 
in  neuropathies  with  gastro-intestinal  atony,  which  at  times  is  accom- 
panied by  achylia.  For  a  stool  having  the  qualities  in  question  the  pseudo- 
colon  type  is  almost  obligatory  and  stands  at  the  summit  of  its  develop- 
mental possibilities.     Less  pronounced  approaches  to  this  type  are  fre- 

"See  Plate,  Fig'.  3. 

"  See  Fig.  4.  The  examinations  of  Professor  Ghon  show  that  this  is  a  type  of 
streptothrix. 


Fig.  I. 

Microscopic  appearance  of  a  growth  of  the  foces 

(Grnm    staining)  in  a  case    of   anatomically    ami 

functionally  perfect  gastro-intestinal  tract. 


Fig.  II. 

Slicroscopic   appearance  of  a  growth  of  the  feces 

(Gram    staining)    in    a    case   of   carcinoma   of  the 

stomach.  One  sees  numerous  firampositive  „laetic 

acid  bacilli". 


Fig.  III. 

Microscopic  appearance   of  a  grovrth  of  the  feces 

(Gram  staining):   „Filiform  type"  with  granulose 

reaction. 


Fig.  IV. 

Microscopic  appearance  of  a  growth  of  the  feces 
(Gram  staining):  pseudo-colon  type. 


These  figures  are  equally  magnified. 


Rebman  Company,  New  York. 


VEGETABLE  AND  BACTERIAL  ORGANISMS     25 

quently  found  with  the  many  different — mostly  chronic — processes  in  the 
large  intestine ;  however,  they  have  no  particular  significance. 

Here,  also,  it  may  be  well  to  emphasize  the  points  of  difference  from 
the  lactic-acid  bacillus : 

Gram-positive,  short  rod-shapes,  without  differences  in  length,  can  be 
cultivated  anacrobically  only.  Stomach  contents  reveals  no  analogous 
growths,  but  may  show  absence  of  HCl  (achylia  gastrica). 


Bearing  in  mind  what  has  been  said  above  it  should  not  be  difficult  to 
properly  recognize  a  growth  of  lactic-acid  bacilli  even  in  the  feces ;  in 
the  stomach  contents  conditions  are  much  simpler,  since,  if  there  be  pres- 
ent Gram-positive  rod-shapes,  having  the  previously  discussed  morpho- 
logical character,  the  lactic-acid  bacillus  is  practically  the  onW  one  that 
deserves  consideration. 

Culture    Demonstration    of    Lactic- 
Acid  Bacilli 

Nevertheless,  should  culture  demonstration  be  desirable  or  easily 
feasible  in  one  or  the  other  case,  it  will  generally  be  sufficient  to  start  a 
growth  on  plates  of  grape-sugar  agar,  as  indicated  previously.  After 
24  or  at  most  48  hours  (at  incubator  temperature  only)  very  small 
colonies  will  appear,  which  remind  one  of  streptococci,  and  which  do  not 
increase  in  size.  The  border  of  the  colonies  is  wavy,  after  the  fashion  of 
the  anthrax  bacillus.  Only  on  very  dry  agar  may  the  colonies  some- 
times have  a  sharp  outline,  and  then  they  are  composed  mostly  of  very 
short  rod-shapes  that  have  not  grown  to  be  threads. 

The  morphological  character  of  the  colonies,  especially  in  so  far  as  it 
belongs  to  the  first-mentioned  type,  which  is  the  standard,  is  sufficient 
for  their  sure  recognition  among  gastro-iiitestinal  bacterial  growths.'^ 


Diagnostic   Significance    of   Lactic- 
Acid  Bacilli  Findings 

As  regards  the  diagnostic  significance  of  findings  of  lactic-acid  ba- 
cilli, be  they  in  the  stomach  or  in  the  feces,  it  is  of  course  no  question  of 
a  specific  symptom  of  gastric  cancer. 

Specific  symptoms,  belonging  only  to  a  certain  definite  disease  process, 
count  among  the  greatest  of  all  rarities,  and  in  the  entire  symptoma- 
tology of  malignant  neoplasms  there  is  no  specific  symptom.  Between 
specific  symptoms  and  inconsequential  manifestations  of  disease  there  are 
a  number  of  gradations. 

And  not  only  here,  but  in  many  other  domains  of  symptomatology 
as  well,  there  ought  not  to  be  carried  on  the  idle  strife  in  regard  to 
specificity  and  non-specificity,  rather  there  should  be  an  agreement  as  to 
what  place  a  certain  symptom  occupies  in  the  line  of  diagnostic  value. 

Concerning  the  vegetation   of  lactic-acid  bacilli   I   can  maintain,  by 

^'  In  regard  to  separation  of  a  morphologically  similar  disease  producer  observed 
by  me  (Gram-positive  ulcerative  mvcosis  of  the  stomach),  see  jR.  Schmidt.  Mitt,  aus  d. 
Grenzgeb.   d.   Med.   ii.   Chir.,   190fi, 'Vol.   XV,   Copy   5,  i>age  705. 


26  TUMORS    OF    THE    ABDOMINAL    VISCERA 

reason  of  inan3'  years'  experience,  that  we  are  here  dealing  with  a  symp- 
tom which  is  of  no  consequence. 

It  seems  to  me  quite  to  the  purpose  to  reiterate  in  a  few  sentences 
the  essence  of  my  personal  experience. 

1.  The  absence  of  lactic-acid  bacilli  vegetation  can  never  be  used  as 
against  the  diagnosis  of  carcinoma  of  the  stomach,  since  advanced  cases 
ma}'^  occasionally  go  on  without  this  finding. 

2.  At  times  one  must  figure  on  variation  in  the  quantities  of  such 
vegetation  in  the  stomach,  whilst  in  the  feces  they  remain  constant. 

3.  An  abundant  vegetation  of  lactic-acid  bacilli  in  the  stomach  con- 
tents always  leads  to  the  occurrence  of  analogous  bacterial  growths  in 
the  feces,  and  the  latter,  as  has  just  been  stated,  may,  despite  their  gas- 
tric origin,  at  times  surpass  the  former  in  intensity. 

4-.  In  very  rare  exceptional  cases  an  abundant  vegetation  of  lactic- 
acid  bacilli  in  tlie  feces  may  also  be  of  intestinal  origin.  In  my  observa- 
tions, extending  over  more  than  ten  \'ears,  I  have  met  with  but  two  such 
cases,  one  being  a  case  of  lymphosarcoma  of  the  small  bowel,  the  other 
a  case  of  cicatricial  stenosis  on  a  tubercular  basis  in  the  lowermost  por- 
tion of  the  ileum."'" 

5.  A  growth  of  lactic-acid  bacilli  in  the  stomach  contents  is  prac- 
tically alwa^'s  of  gastric  origin,  and  in  the  majority  of  cases  coincides 
with  the  existence  of  carcinomatous  disease  of  that  organ. 

6.  From  my  observations  during  more  than  ten  years  I  can  recall 
but  three  exceptional  cases  in  which  there  was  no  carcinomatous  disease 
of  the  stomach : 

a.  Cicatricial  pyloric  stenosis  following  HCl  erosion  (operution). 

b.  Carcinoma  of  the  gall-bladder  (autopsy). 

c.  Cicatricial  pyloric  stenosis  with  synchronously  existing  kidney 
tumor  of  Grau'itz. 

In  all  of  these  cases  there  was  pyloric  stenosis  and  "coffee-ground" 
vomiting. 

7.  Isolated  lactic-acid  bacilli,  be  they  in  the  stomach  contents  or  in 
the  feces,  must  be  used  with  utmost  precaution  for  diagnostic  purposes, 
especially  when  dealing  with  "agonal"  conditions,  such  as  sepsis  and 
peritonitis,  which  cases  are  occasionally  accompanied  by  coffee-ground 
vomiting. 

8.  The  absence  of  lactic-acid  bacilli  when  there  is  "coffee-ground" 
vomiting  (as  in  hyperacidity,  benignant  pyloric  stenosis,  gastric  crises, 
intestinal  stenosis,  peritonitis,  congestive  catarrhal  conditions,  etc.),  may 
generally  be  constinied  as  against  the  diagnosis  of  gastric  carcinoma. 

B.    Sarcince  of  the  Stomach 

As  a  result  of  my  examinations  I  have  become  convinced  that  the  ex- 
aminations of  gastric  sarcinae,  made  by  Oppler  in  his  day,  are  entirely 
erroneous. 

"*R.  Schmidt.  Beitriige  zur  abdominalen  Diagnostik.  Med.  Klin.,  1909,  No.  2, 
page  7. 


VEGETABLE  AND  BACTERIAL  ORGANISMS     27 

Those  sarcinfc  which  can  ahiiost  without  exception  he  demonstrated 
in  hirge  nunihcrs,  hoth  in  the  stomach  contents  and  in  the  feces  in  every 
case  of  benignant  organic  stenosis  of  the  pylorus,  have  nothing  in  com- 
mon with  tlie  different  kinds  of  pigment-forming  sarcina'  of  the  air. 

Entirely  different  in  shape  and  size,  the  stomach  sarcina'  do  not  ad- 
mit of  cultivation  in  customary  nutritive  media.  Their  abode  within 
the  human  organism  is  in  the  stomach ;  only  from  here  do  they  gain  ac- 
cess to  the  feces,  without  ever  settling  primarily  in  the  feces,  never  ap- 
pearing in  the  urine,  and  never  in  the  air-passages.  The  appearance  of 
gastric  sarcina?  is  therefore  limited  to  the  stomach,  in  perfect  contrast  to 
the  ubiquitous  presence  of  the  various  kinds  of  air  sarcin.e;  the  question 
of  its  origin  remains  entirely  unsolved. ^^ 

Despite  the  impossibility  to  cultivate  stomach  sarcina?,  it  is  perhaps 
never  difficult,  with  some  experience  in  the  domain  of  gastro-intestinal 
vegetations,  to  properly  recognize  them  because  of  their  size  and  con- 
spicuous bale  shape.  Also,  as  already  emphasized,  one  can  easily  pro- 
cure gastric  contents  containing  stomach  sarcinae,  which  can  be  preserved 
by  keeping  air-tight  after  the  addition  of  a  few  drops  of  formol. 

Morphologically,  two  forms  are  to  be  distinguished : 

Large-Celled  Form    (lodin  Positive) 

1.  A  large-celled  form.  The  dice  formation  is  mostly  very  exact,  and 
with  Lugol's  solution  there  appears  an  extensively  yellow  coloration 
(iodin  positive  forai). 

Small-Celled  Form   {Iodin  Negative) 

2.  A  small-celled  form.  There  is  a  tendency  to  the  formation  of  more 
irregular,  globular  masses,  the  individual  sarcinae  are  really  smaller,  and 
sometimes  have  spore-like  inclusions  that  are  able  to  shut  off  the  light. 
There  is  no  coloration  with  iodin  (iodin  negative  form).  The  irregular 
masses  often  appear  honeycombed  or  like  the  spawn  of  frogs. 

Since  both  forms  are  constantly  to  be  found — though  one  n\a.y  be 
more  prevalent  than  the  other — I  think  that  we  are  simply  concerned 
with  different  stages  of  development  of  one  and  the  same  species,  though 
the  iodin  positive  form  seems  to  require  the  more  favorable  conditions  of 
life. 

In  the  bowel  the  sarcinas  coming  from  the  stomach  undergo  degen- 
erative changes,  and  the  large-celled  sarcina?  often  appear  as  if  washed 
out  and  shadowy,  comparable  to  red  cells  of  the  same  description  oc- 
curring in  nephritic  urinary  sediment ;  there  may  also  be  observed  dis- 
integrating processes  in  the  outline  (bale,  dice)  itself.  As  regards  the 
diagnostic  utilization  of  stomach  sarcinje,  I  would  like  to  summarize  the 
results  of  my  experience,  as  follows : 

a.  For  the  diagnostic  application,  it  makes  no  difference  whether  the 
stomach  sarcina"  are  found  in  the  stomach  contents  or  in  the  feces  ;  for 
in  the  latter  case  they  originate  in  the  stomach. 

''  In  an  older  work  from  the  year  1849,  Virohow's  Arohiv,  page  331,  O.  W.  Simon 
has  expressed  the  opinion  that  stomach  sarcinae  represented  a  stage  of  development 
of  yeast-cells.      T   consider  this  opinion  worthy  of  discussion. 


28  TUMORS    OF    THE    ABDOMINAL    VISCERA 

b.  Vegetation  of  stomach  sarcinfe  occurs  only  in  connection  with  a 
high  degree  of  stagnation  of  stomach  contents.  If  the  finding  is  constant 
it  proves,  almost  always,  the  existence  of  organic  stenosis  in  the  neigh- 
borhood of  the  pylorus  or  duodenum. 

c.  The  finding  of  a  malignant  tumor-mass  in  the  supra-umbilical 
parts  of  the  abdomen,  besides  the  demonstration  of  the  stomach  sarcinse 
in  the  stomach  contents  or  feces,  suggests,  in  the  first  place,  carcinoma 
of  the  pylorus  ;  besides  this,  we  most  frequently  have  to  consider  carci- 
noma of  the  head  of  the  pancreas  or  the  gall-bladder,  with  secondary  ste- 
nosis of  the  stomach  outlet. 

d.  Constant  finding  of  sarcinje  in  cases  of  stomach  disease  which  is 
of  short  duration — say  several  months — usually  due  to  a  malignant 
process  (most  frequently  pyloric  cancer)  ;  the  same  is  true  of  the  com- 
bination :  sarcin<e-vegetation  -|-  growths  of  lactic-acid  bacilli. 

e.  The  occurrence  of  stomach  sarcin<E  without  stenosis  of  the  pylorus 
counts  among  the  greatest  rarities ;  in  the  course  of  many  years  I  have 
been  able  to  observe  only  a  few  such  exceptional  cases,  although  I  was 
always  on  the  lookout  for  same ;  once  a  case  of  deep-seated  carcinoma  of 
the  esophagus  and  in  another  of  accretion  of  the  stomach  in  tuberculous 
peritonitis.  In  both  cases  the  occurrence  of  sarcinae  was  not  permanent, 
but  only  temporary. 

C.    Further  Findings 

The  diagnosis  of  malignant  diseases  of  the  gastro-intestinal  tract 
frequently  meets  Avith  so  many  difficulties,  that  one  will  occasionally  avail 
himself  of  symptoms  wliich  do  not  possess  the  value  that  attaches  to  lac- 
tic-acid bacilli  and  stomach  sarcinfe  vegetations. 

Megastoma  Entericum 

Here,  as  belonging  to  the  realm  of  gastro-intestinal  bacterial  and 
plant  vegetation,  we  must  take  into  consideration  the  finding  of  cer- 
c-omonas  intestinalis  (Lamhl)  s.  Megastoma  entericum  (Grassi),^'-  in  so 
far  as  it  is  met  with  in  the  stomach  contents. 

These  parasites,  belonging  to  the  flagellates,  have  so  far  been  found 
in  the  stomach  almost  exclusively  in  connection  with  carcinomatous  dis- 
eases, though  on  the  whole  their  occurrence  is  quite  rare.  They  are  of  a 
pear-shaped  form,  about  twice  the  size  of  a  red  blood  cell,  with  two  eye- 
like nuclei  in  the  broad  end  of  their  body. 

The  conditions  favoring  their  multiplication  in  the  stomach  seem  to 
be  as  follows : 

1.  Alkaline  reaction. 

2.  Presence  of  special  hiding-places  on  the  inner  surface  of  the  stom- 
ach, as  established  chiefly  by  papillary  cancer  proliferations. 

The  cases  observed  so  far  always  showed  non-obstructing  neoplasms, 
located  for  the  most  part  in  the  fundus  of  the  stomach;  being  in  definite 

^^  Hensen,  Deutsches  Arch.  f.  Klin.  Med.,  Vol.  59,  page  450  (first  observation); 
Cohnheim,  Deutsch.  med.  Wochenschr.,  1903,  page  230,  illustration,  page  206;  Zabel, 
Wiener  Klin.  Wochenschr.,  1904,  38  (illustrations). 


VEGETABLE  AND  BACTERIAL  ORGANISMS     29 

contrast  to  the  appearance  of  the  hvctic-acid  bacilhis,  whicli  doubtless  has 
special  preference  for  carcinoma  at  the  pylorus. 

The  eventual  finding  of  a  megastoma  vegetation  in  the  stomach  con- 
tents ^^  deserves  particular  attention,  because  of  the  scanty  symptoma- 
tology of  non-obstructing  cancer  of  the  fundus,  and  because  a  palpable 
tumor  is  mostly  absent. 

Of  unequally  less  diagnostic  import  is  such  a  finding  in  the  feces ; 
here  the  parasites  appear  mostly  encysted  and  at  rest,  and  are  of  oval 
formation.  Occasionally  they  might  be  of  gastric  origin,  but,  as  a  rule, 
when  the  stomach  contents  are  negative  with  reference  to  parasitic  find- 
ings, we  are  dealing  with  an  autochtomous  intestinal  growth  that  has 
come  to  development  coincident  with  the  existence  of  gastric  hypoacidity, 
a  condition  Avhich,  for  that  matter,  is  almost  the  rule  in  the  case  of  other 
parasites,  such  as  tenia?.  It  seems  that  the  gastro-intestinal  tract  is  more 
accessible  to  parasitic  invasion  when,  due  to  weakness,  it  is  functionating 
below  the  normal. 

Bacterium  Coli 

In  cases  of  carcinoma  of  the  stomach  the  colon  bacillus  and  related 
species  (e.g.,  bact.  lactis  aerogenes)  show  up  more  pronouncedly  in  the 
Gram-picture  or  in  the  respective  plate  cultures  when  extensive  disinte- 
gration of  the  new  formation  has  taken  place,  and  such  cases  may, 
through  the  local  establishment  of  a  kind  of  intestinal  vegetation  even 
without  connnunication  with  the  gut,  exliibit  fecal  stomach  contents.  In 
connection  with  lactic-acid  fermentation  in  carcinomatous  stomach  con- 
tents, the  microbes  mentioned  above  might  be  of  more  real  import  than 
the  so-called  lactic-acid  bacilli. 

According  to  ni}^  observation,^'*  it  seems  that  colon  bacilli  vegeta- 
tion, so  far  as  its  abundant  occurrence  is  concerned,  is  a  peculiarity 
with  those  rarer  forms  of  gastric  carcinoma  in  which  there  takes  place  a 
uniform  diffuse  infiltration  of  the  stomach-walls  in  toto,  without  any 
proper  tumor- formation  (so-called  linitis  plastica  Brinton).  In  the  fresh 
preparations  from  these  cases  the  colon  bacilli  were  conspicuous  for  their 
small  size,  and  appeared  almost  like  cocci.  In  the  streak  cultures  there 
were  close  areas  of  colon  bacilli. 

Vegetation  in  Feces  in  Connection  ivith 
Neoplasms  of  the  Bowel 

So  far  as  neoplasms  of  the  intestinal  tract  are  concerned,  the  picture 
afforded  by  vegetation  in  the  feces  does  not  show  any  findings  that  are 
nearly  as  important  as,  for  instance,  the  lactic-acid  bacillus  is  in  cancer 
of  the  stomach. 

The  following  three  findings,  however,  seem  to  me  to  deserve  atten- 
tion, as  they  occur  only  in  cases  of  severe  organic  lesions  of  the  bowel. 

1.  Lively  motile  rod-shaped  forms.     If  the  smallest  possible  particle 

^^  For  this  jnirpose  it  might  be  especially  well  to  examine  the  sediment  of  the 
irrigation  fliiid. 

**  Uber  Mesentericus.  ii.  Colihacillose  des  Magens.  Wiener  Klin.  Wochenschr., 
1901,  2. 


30  TUMORS    OF    THE    ABDOMINAL    VISCERA 

of  stool  is  floated  in  a  drop  of  water  and  observed  under  the  microscope, 
the  rod-shaped  bacilli  that  are  to  be  examined  show  throughout  an  in- 
dolent molecular  motion  in  one  and  the  same  place,  or  passive  motion  due 
to  currents  of  fluid.  Automotion,  in  the  sense  that  individual  rod-shapes 
"shoot  about,"  cross  the  microscopic  field,  etc.,  is  an  extremely  rare  oc- 
currence. According  to  my  observations,  it  is  found  only  with  the  severer 
organic  bowel  lesions,  among  others — carcinomata. 

2.  Abundant  presence  of  spirochetes.  As  compared  to  the  spirocheta 
pallida  of  Schaud'mn,  the  intestinal  spirochete,  with  its  scanty  and  bold 
curves,  is  easily  recognizable  even  unstained,  especially  at  the  edge  of 
a  hanging  drop,  also  with  the  Gram  or  Giemsa  preparation ;  its  abundant 
presence  coincides  mostly  with  severe  catarrhal  conditions  of  the  large 
bowel,  among  others  with  carcinoma  of  the  large  intestine. 

3.  In  some  cases  of  cancer  of  the  large  intestine  I  have  been  im- 
pressed with  the  abundance  of  cocci  that  show  up  with  the  Gram  stain, 
and  arc  arranged  in  large  heaps.  Exulcerating  surfaces  may,  of  course, 
occasionally  serve  as  nutritive  media  for  the  development  of  pus  or- 
ganisms.    Still,  the  finding  is  far  from  being  constant  or  specific. 

I  note  the  especial  copiousness  of  cocci  in  the  feces  in  many  cases 
of  pernicious  anemia. 

Ehrlich's  ''Diazo""  and  ''Aldehyde^'  Reaction 

For  many  years  I  have  given  full  attention  to  both  of  the  above 
urinary  reactions,  even  in  connection  with  the  malignant  diseases  here 
under  discussion,  and  I  have  repeatedly  made  use  of  them  with  diagnostic 
advantage.  I  give  space  for  their  separate  discussion  because  as  yet 
they  have  received  too  little  appreciation  from  physicians  in  general,  al- 
though the  simplicity  of  their  performance  makes  them  accessible  for 
every  man. 

For  the  diazo  reagents  I  employ  the  following,  according  to  Frieden- 
xvaJd — -Ehrlich  : 

1.   Paramidoacetophenon     1.0 

Acid,   hydrochlorici   concentrati 50.0 

AqujE  Destillatc-e    1000.0 

II.   Natrii  nitrosi    0.5 

Aqua?  Destillata?    100.0 

Pour  into  a  test-tube  about  3  cm^  of  reagent  I  and  add  one  to  two 
drops  ^^  of  reagent  II;  mix  with  an  approximately  equal  quantity  of 
urine  and  add  about  1  cm^  of  ammonia. 

The  reaction  can  be  considered  as  positive  only  when  the  foam  that 
is  generated  by  shaking  has  an  undoubted  red  color  (not  brown).  Light 
rose  =  weakly  positive;  scarlet  red  =  strongly  positive. 

Ehrlich's  original  observation,^^  according  to  Avhich  the  "diazo"  re- 

*'  An  excess  of  reagent  II  may  lead  to  a  falsely  negative  reaction. 
"P.    Ehrlich.      Uber   eine    neiie    Harnprobe.      Zeitschr.    f.    Klin.    Med..    1883,    page 
285;   Charite   Annalen,   1883,  page   140. 


VEGETABLE  AND  BACTERIAL  ORGANISMS     31 

action  is  absent  in  afebrile  processes,  hence  also  in  cancer,  is  quite  jus- 
tified in  so  far  as  it  lays  down  a  rule  which  has  not  many  exceptions. 

Certainly  the  fever  as  such  has  nothing  to  do  with  the  occurrence  of 
the  reaction.  For,  as  Ehrlich  already  emphasized,  these  are  infectious 
processes  with  liigh  fever,  which  are  only  exceptionally  accompanied  by 
diazo  reaction,  e.g.,  croupous  pneumonia,  acute  articular  rheumatism, 
diphtheria,  whilst  otlier  infectious  processes  with  much  less  fe])rilc  va- 
riation show  an  almost  constant  diazo  reaction  in  the  urine,  e.g.,  miliary 
tuberculosis,  typhoid,  morbilli. 

These  facts  seem  to  indicate  that  the  febrile  metabolism,  as  such, 
plays  a  lesser  part  in  the  causation  of  the  diazo  reaction  than  the  kind  of 
toxin  operating  at  the  time. 

And  this  manner  of  conception  explains  those  cases,  indeed  very  rare, 
which  are  occasionally  accompanied  b^^  a  strong  diazo  reaction,  although 
the  course  of  the  disease  is  afebrile  or  only  subfebrile. 

For  abdominal  non-malignant  pathological  processes  I  would  like  to 
set  up  the  following  scale  of  frequency  taken  from  my  observation : 

I.  Reaction  almost  always  positive  and  mostly  maximal. 

a.  Tuberculosis  of  the  peritoneum ;  including  cases  which  are  afebrile 
or  have  only  slight  elevations  in  temperature.  In  these  cases  the  reaction 
has  no  palpable  prognostic  meaning,  and  its  occurrence  does  not  depend 
on  pulmonic  complications, 

b.  Enteric  fever:  The  reaction  not  rarely  becomes  obscure  about  a 
week  prior  to  the  disappearance  of  the  fever. 

c.  Parametritis   with   post-puerperal   streptoccean    reaction."' 

II.  Intermittentl}^  positive,  often  only  moderate  reaction. 

(t.  Tubercular  ulcers  of  the  intestines  and  tubercular  tumor  of  the 
cecum ;  also  tuberculosis  of  the  female  genitalia  and  general  tubercular 
adenitis  of  the  abdomen. 

Since  all  these  affections  rarely  appear  by  themselves,  but  are  mostly 
in  combination,  and  are  often  also  accompanied  by  foci  in  the  bones  and 
in  the  lungs,  it  is  difficult  to  estimate  the  influence  of  the  individual 
lesion.  As  a  rule,  the  reaction  is  so  much  more  pronounced  as  the  general 
infection  overshadows  the  local  anatomical  process,  in  w^hich  cases,  for 
that  matter,  higher  fever  temperatures  may  be  entirely  wanting. 

/).   Cholangitic  Infections.  ^^ 

Ulcerative  processes  of  the  duodenum  with  ascending  infection  of  the 
biliary  passages  may,  in  this  way,  occasionally  go  along  with  diazo  reac- 
tion ;  similarly,  some  cases  of  cholelithiasis  are  accompanied  by  diazo 
reaction,  which  in  such  cases,  however,  is  usually  very  moderate  and  of 
short  duration. 

^'  According  to  my  own  observation,  cases  of  general  staphylococcus  infection  run 
their  course,  as  a  rule,  without  any  diazo  reaction.  The  maximal  constant  diazo 
reactions  in  streptococcus  sepsis  stand  in  peculiar  contrast  to  the  almost  constantly 
negative  reaction   in  acute  articular  rheumatism. 

^'*  With  positive  reactions  in  these  cases,  streptococci  and  colon  bacilli  niiglit  be 
particularly  considered  analogous  to  other  observations.  1  woiild  consider  the  ex- 
istence of  diplococcus  or  staphylococcus  infection  of  the  bile-jiassage  as  highly  im- 
probable in  the  jiresence  of  a    jHisitive  diazo  reaction. 


32  TUMORS    OF    THE    ABDOMINAL    VISCERA 

III.  Reaction  constantly  negative. 

Cirrhosis  of  Laennec,  myeloid  leukemia,  ascites  due  to  cardiac  and 
portal  congestion,  catarrhal  jaundice,  chronic  gastro-intestinal  catarrh, 
simple  ulcer. ^'' 


Diazo  lieaciion  Neoplasms 

In  the  scale  of  frequency  and  intensity  of  the  diazo  reaction,  as  out- 
lined above,  I  would  include  malignant  diseases  of  the  abdomen  between 
groups  I  and  II :  reactions  seldom  and  even  then  feebly  positive. 

The  tumor  process,  as  such,  could  hardly  give  rise  to  a  positive  diazo 
reaction.  I  lean  to  the  belief  that  when  malignant  diseases  of  the  abdo- 
men occur  with  diazo  reaction,  we  are  probably  always  dealing  with 
secondary  infections  (streptococci,  colon  bacilli). 

Accordingly,  in  the  cases  where  there  was  a  positive  reaction  (and 
they  were  rare)  in  connection  with  stomach  cancer,  I  found  that  the  lat- 
ter was  mostly  of  the  medullary  type  and  exulcerating  very  much.  Fi- 
brous forms,  ulcerating  but  little,  seem  almost  never  to  be  accompanied 
by  diazo  reaction. 

The  observation  that  cancer  of  the  bile-passages,  particularly  the 
gall-bladder  and  terminal  portion  of  the  ductus  choledochus,  also  the 
papilla  of  Voter,  yields  about  the  most  frequent  positive  results,  also 
leads  me  to  the  assumption  that  in  cases  of  malignant  abdominal  diseases 
the  diazo  reaction  is  dependent  upon  secondary  infection.  Here  the  con- 
ditions for  secondary  infection,  considered  as  belonging  to  the  cholan- 
gitic  processes,  are  particularly  favorable. 

Here,  as- in  typhoid,  it  is  possible  that  complications,  such  as  the  oc- 
currence of  purulent  peritonitis,  may  cause  the  reaction  to  disappear. 

Even  though  I  am  inclined  to  look  at  the  diazo  reaction  in  malig- 
nant diseases  as  a  symptom  of  secondary  infection,  its  diagnostic  value 
seems  to  me  really  greater  than  that  of  findings  of  eventual  rises  in  tem- 
perature. For,  leaving  aside  the  fact  that  the  latter  may  easily  be  ab- 
sent as  the  result  of  cachexia,  the  diazo  reaction  has,  as  already 
previously  emphasized,  a  specific  meaning,  even  though  it  be  within  wider 
limits,  and,  indeed,  certain  highly  febrile  infectious  processes  (pneu- 
monia, malaria,  etc.)  at  times  run  their  course  without  this  urinary 
finding. 

Diagnostic  Value  of  Diazo  Reaction  in 
Malignant  Processes  of  the  Abdomen 

As  regards  the  specific  diagnostic  value  of  the  diazo  reaction  in  the 
province  of  malignant  diseases  of  the  abdomen,  the  following  points  of 
view  seem  to  me  worthy  of  special  mention : 

1.  The  combination  of  ascites  with  a  strongly  positive  diazo  reac- 
tion permits  the  exclusion  of  an  uncomplicated  cirrhosis  of  Laennec,  as 

^'  An  exception  to  this  is  a  case  of  Gram-positive  mycosis  of  the  stomach,  so 
far  observed  by  myself  alone,  which  showed  a  constant  diazo  reaction.  See  Sitz.-Ber. 
d.  Ges.  f.  innere  Med.  ii.  Kinderheilk.,  February  25,  1904,  and  Zeitschr.  f.  Heilk., 
1905,  Vol.  XXVI,  Copy  7;   Abteil.   f.   prakt.  Anat.,  Copy  3. 


VEGETABLE  AND  BACTERIAL  ORGANISMS     33 

well  as  cardiac  congestion.  For  differential  diagnosis  there  really  re- 
main only  tuberculosis  of  the  peritoneum  and  ascites  resulting  from  a 
malignant  neoplasm,  tlie  latter  assumption,  however,  being  highly  im- 
probable. 

2.  Ascites  without  diazo  reaction  makes  peritoneal  tuberculosis  very 
improbable.  In  this  case  the  probabilities  are  about  evenly  divided  be- 
tween cardiac  and  portal  congestion  and  neoplasm. 

3.  In  the  differential  diagnosis  of  gastro-intestinal  cancer  on  tbe  one 
hand  and  gastric  or  intestinal  catarrh  on  the  other,  a  positive  diazo  reac- 
tion would  favor  the  assumption  of  the  former. 

4.  In  the  differential  diagnosis  of  carcinoma  and  tubercular  tumor 
of  the  cecum  a  positive  diazo  reaction  makes  the  latter  much  more 
probable. 

5.  In  the  differential  diagnosis  of  senile  tuberculosis  and  gastric  can- 
cer, a  clearly  positive  diazo  reaction  makes  much  more  for  the  first 
assumption. 

Aldeliy'de  Reaction 

Another  reaction,  which  like  EJirlich's  diazo  reaction  and  because  of 
its  simplicity  and  diagnostic  import  deserves  to  become  the  common  prop- 
erty of  medical  men,  is  the  aldehyde  reaction,  also  inaugurated  by 
Ehrlich. 

At  first  misinterpreted  ^ **  as  to  its  causative  significance,  the  investi- 
gations of  Poppenhelm,  Neubauer  and  Bauer  "^^  demonstrated  that  the 
occurrence  of  this  reaction,  as  well  in  the  urine  as  in  the  feces,  is  syn- 
chronous with  the  presence  of  urobilinogen. 

For  the  performance  of  this  test  I  recommend  the  following  solution, 
which  is  a  little  at  variance  with  the  original  prescription : 

Dimethylamidobenzaldehyde    2.0 

Acidi  hydrochlorici  concentrati 100.0 

Sig.     Aldehyde  reagent;  to  be  added  drop  by  drop. 

The  reagent  is  added  drop  by  drop  to  the  urine  that  is  to  be  exam- 
ined, whereupon  an  intensive  red  color  appears  if  there  be  present  a 
large  amount  of  urobilinogen,  the  color  disappearing  upon  addition  of 
an  excess  of  the  reagent ;  hence  the  addition  of  drop  after  drop,  though 
not  too  timorously.  When  urine  is  exposed  to  sunlight  for  a  length  of 
time  any  urobilinogen  that  may  be  present  is  converted  into  urobilin, 
which  latter  does  not  react  with  the  reagent,  hence  might  arise  the  theo- 
retic requirement  to  obtain  freshly  voided  urine  which  only  contains  uro- 
bilinogen. Practically,  this  requirement  is  modified  by  the  fact  that  this 
conversion  takes  place  very  slowly  under  ordinary  external  conditions. 

The  same  is  true  of  feces,  which  in  their  fresh  state  mostly  contain 
urobilinogen  only,  which  also  in  this  case  but  slowly  changes  into  urobilin. 

In  the  examination  of  feces  for  urobilinogen,  it  is  advisable  to  mix  a 

*"  Ehrlich^s  dimethylamidobenzaldehvcl  reaction.  Zeitschr.  f.  Physiol,  u.  Chemie, 
1900-1901,   No.  31,   p.  520. 

"Dr.   R.  Bauer.    Zentralhl.  f.  innere  Med.,  1905,   No.  34. 


34  TUMORS    OF    THE    ABDO:\IIXAI.    VISCERA 

portion  about  the  size  of  a  pea  (at  times  only  a  few  loopfuls)  with  2  to 
3  cm^  60%  alcohol  in  a  porcelain  dish  by  means  of  a  glass  rod,  then 
adding  the  reagent  to  this  alcoholic  extract  (filtration  is  superfluous). 
If  an  equal  quantity  of  feces  and  alcohol  are  used  we  are  enabled  to  make 
a  quantitative  estimate. 

In  decided  contrast  to  the  previously  discussed  diazo  reaction,  which 
must  be  considered  as  pathological  even  if  of  slight  degree  of  intensity 
(light  rose- red  coloration),  moderate  degrees  of  a  positive  aldehyde  re- 
action in  the  urine  are  hardly  of  value.  They  manifest  themselves  through 
slight  and  mostly  delayed  red  coloration  in  from  one  to  two  minutes. 
Indeed,  there  are  many  instances  in  which  even  this  slight  degree  of  a  posi- 
tive reaction  is  wanting. 

At  any  rate,  the  reaction  becomes  of  full  diagnostic  value,  then,  only 
when  it  turns  out  strongly  positive,  which  is  determined  by  its  rapid 
onset  and  intense  red  coloration. 

As  already  mentioned,  the  significance  of  a  strongly  positive  alde- 
hyde reaction  in  the  urine  is  identical  with  that  of  a  pronounced  urobili- 
nogenuria. 

The  question  arises,  therefore,  as  to  the  general  significance  of  this 
manifestation  and  its  special  diagnostic  value  within  the  limits  of  the 
topic  in  which  we  are  here  interested. 

My  opinions  are  as  follows  : 

Origin  of  Vrohilinogen 

1.  The  intestine  (large  bowel)  is  practically  considered  as  the  place 
of  origin  of  urobilinogen,  and  bilirubin  of  the  bile  as  the  material  from 
which  it  springs. 

2.  Normally,  a  portion  of  iiitestin;d  urobilinogen  reaches  the  liver 
through  resorption  into  the  portal  vein,  and  from  the  liver  it  is  almost 
quantitatively  eliminated  into  the  bile  and  with  it  again  returns  to  the 
bowel    ("small   circulation"'). 

Causo  of  its  Passage  into  the   Urine 

3.  If  for  any  reason  (thick  consistency  of  the  bile,  moderate  vis  a 
tergo,  obstacles  to  evacuation  on  account  of  swelling  of  the  mucous  mem- 
brane, occlusion,  etc.,  of  the  bile-passages)  the  flow  of  bile  be  impeded, 
it  is  possible,  probably  because  of  the  overloading  of  the  liver-cells  with 
bile  coloring  matter,  for  a  portion  of  the  urobilinogen  normally  resorbed 
from  the  bowel  to  pass  the  liver-cells,  gain  access  to  the  large  circulation, 
thence  to  be  excreted  by  the  kidne3's. 


If  the  boAvel  be  the  place  of  formation  of  urobilinogen,  then  the  liver 
is  the  organ  which,  because  of  partial  disturbance  in  its  function  of 
biliary  elimination,  determines  the  transition  of  intestinal  urobilinogen 
into  the  circulation  and  from  there  through  the  kidneys  into  the  urine. 

According  to  this  view,  every  urobilinogenuria  of  high  degree  would 
ultimately  have  to  be  interpreted  as  an  hepatic  symptom. 


VEGETABLE  AND  BACTERIAL  ORGANISMS     35 

Febrile  Urohilinogenuria 

Indeed,  it  is  illogical  to  speak  of  a  febrile  urohilinogenuria,  since  the 
fever,  as  such,  is  never  the  cause  of  this  phenomenon,  it  being  well  known 
that  high  febrile  diseases,  as  is  most  often  the  case  in  typhoid,  run  their 
course  witliout  urohilinogenuria. 

In  these  cases  also  the  clinical  observations,  for  example,  in  pneu- 
monia, absolutely  speak  for  the  hepatic  origin  of  the  symptom,  pre- 
sumably, in  the  way  of  an  accompanying  cholangitis. 

Hematogenous  (?)   Urohilinogenuria 

If,  with  the  existence  of  a  general  hemorrhagic  diathesis,  there  are 
multiple  hemorrhages  from  the  skin,  mucous  membranes  and  muscles, 
there  is  also  here  no  cogent  reason  to  speak  of  "hematogenous"  uro- 
hilinogenuria. 

These  diseases  are  rather  such  in  which  there  is  present  chronic  alco- 
holism, or  in  which  we  are  concerned  with  the  toxic  ejffects  of  infection, 
intestinal  diseases,  etc. ;  so  that,  also,  in  these  instances  the  assumption  of 
pathological  conditions  of  the  liver  is  to  hand  and  actuall}^  too,  objective 
changes  in  the  organ  are  not  seldom  found. 

Clinically,  therefore,  I  adhere  to  the  principle:  without  disturbances 
of  the  liver  function  there  is  no  pathological  urohilinogenuria.  The  na- 
ture of  the  disturbance,  however,  seems  to  me  to  be  the  drainage  of  bile. 

"Aldehyde"  Reaction:  Biliary  Ohstruction 

Malignant  diseases  of  the  abdomen  not  infrequently  have  their  origin 
in  the  liver  or  involve  the  bile-passages  secondarily  (carcinoma  of  the 
duodenum,  pancreas,  secondary  carcinoma). 

The  significance  of  the  aldehyde  reaction  lies  in  the  fact  that,  because 
of  its  simplicity,  it  enables  the  practitioner  to  clearly  acquaint  himself 
Avith  the  conditions  of  the  bile  drainage  from  the  intrahepatic  bile-ducts. 

Especially  the  demonstration  of  just  beginning  or  very  slight  biliary 
congestion  in  particular  is  successful  only  by  means  of  the  testing  of  the 
urine  for  urobilinogen.  If  there  already  exist  a  definite  subicteric  or 
icteric  discoloration,  then  the  reaction — at  least  in  the  urine — loses  in 
significance. 

If  in  such  cases  the  reaction  is  positive,  it  proves  nothing  more  than 
the  skin  discoloration. "*"  If  the  reaction  is  negative — and  according  to 
my  own  experience  this  is  not  rare  in  cases  of  moderately  severe  jaun- 
dice— it  admits  of  no  further  conclusions.  It  would  be  entii*ely  wrong  to 
assume  total  biliary  occlusion  because  of  the  continued  absence  of  the 
formation  of  urobilinogen  in  the  bowel.  One  can  easily  convince  himself 
that  in  such  cases  of  incomplete  biliary  obstruction  urobilinogen  is 
clearly  demonstrable  in  the  feces,  although  there  is  no  aldehyde  reaction 
in  the  urine. 

The  following  explanation  seems  to  fit  these  somewhat  paradoxical 
cases : 

"  With  obscure  subicteric  discoloration  it  is,  indeed,  a  welcome  confirmation  of 
what  is   found  on  inspection. 


36  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Biliary  congestion  is  undoubtedly  a  factor  favoring  the  appearance 
of  urobilinogen  in  the  urine.  Therefore,  subicteric  discoloration  almost 
always  goes  along  with  a  strong  aldehyde  reaction.  But  as  the  biliary 
congestion,  through  its  increasing  intensity,  diminishes  the  amount  of 
bilirubin  in  the  bowel,  hence  also  the  material  from  which  urobilinogen  is 
formed,  there  is  at  the  same  time  a  factor  which,  in  its  normal  develop- 
ment (complete  biliary  obstruction),  to  a  certain  extent  halts  the  forma- 
tion of  urobilinogen  in  its  incipiency. 

Now,  it  seems  that  these  forces  residing  in  the  process  of  biliary  con- 
gestion but  working  in  an  opposite  direction  may  accumulate,  so  that, 
despite  the  existing  congestion  of  bile  and  despite  the  presence  of  uro- 
bilinogen in  the  bowel  contents,  the  urine  show5  normal  conditions  as  far 
as  the  aldehj'de  reaction  is  concerned,  in  other  words,  it  reacts  negatively. 

Since,  therefore,  the  investigation  of  the  urine  with  reference  to  alde- 
hyde reaction  has  little  meaning  where  a  definite  jaundice  is  present,  the 
examination  of  the  feces  in  these  cases  becomes  so  much  more  valuable. 

Only  in  this  way  can  we  expect  to  arrive  at  a  reliable  conclusion  as 
to  the  quantity  of  bilirubin  that  has  gained  access  to  the  bowel. 

If  there  be  total  occlusion  of  the  ductus  choledochus  the  testing  of 
the  feces  for  urobilinogen  may  result  entirely  negative,  or  there  may  be 
found  only  traces  of  urobilinogen,  derived  from  that  bilirubin  which 
has  come  into  the  bowel  with  the  secretions  of  the  intestinal  mucous 
membrane. 

IMere  inspection  of  the  stools  may  lead  to  gross  errors,  as  the  color 
of  the  feces  is  influenced  by  several  factors,  such  as  nutriment,  admixture 
of  blood,  medicaments,  etc. 

Aldehyde  reaction  in  stomach  contents  that  have  been  vomited  or  ob- 
tained by  means  of  the  stomach-tube  proves  only  the  presence  of  bile, 
which  even  under  normal  conditions  contains  urobilinogen. 

Recapitulation 

With  reference  to  the  diagnosis  and  differential  diagnosis  of  malig- 
nant diseases  of  the  abdomen,  the  following  points  of  view  should  receive 
special  prominence. 

1.  The  aldehyde  reaction  in  alcoholic  extract  of  feces,  like  the  bili- 
rubin test  in  urine,  permits  of  the  uninterrupted  estimate  of  bile  drain- 
age into  the  bowel ;  the  icteric  color  of  the  skin  is  not  reliable  as  a 
graduator,  because  it  may  outlast  for  a  longer  time  the  reopening  of  the 
bile-passages.  Complete  drying  up  of  the  biliary  secretion,  as  happens 
particularly  with  malignant  stenosing  processes  (cancer  of  the  head  of 
the  pancreas),  is  shoAATi  in  the  feces  by  complete  or  nearly  complete 
absence  of  the  aldehyde  reaction. 

2.  Slight  degrees  of  a  positive  aldehyde  reaction  in  the  urine  (mostly 
delayed  appearance  of  a  light  red  coloration)  have  no  real  significance 
in  so  far  as  they  are  transient  findings. 

3.  A  strongly  positive  aldehj^de  reaction  in  the  urine  is  always  a 
sign  of  impeded  drainage  of  bile;  in  these  cases  precisely  the  mildest 
forms   of  biliary   congestion   give   rise   to   a   strongly   positive   reaction, 


SYMPTOMATOLOGY    OF    CACHEXIA  37 

even  before  the  appeurance  of  a  subicteric  coloration,  whilst  medium  and 
high  degrees  of  icterus  frequently  run  along  with  aldehyde  reaction. 

4.  We  must  also  take  into  consideration  whether  the  reaction  in  the 
urine  is  constant  or  only  transient/'*  whether  it  is  stationary,  increasing 
or  decreasing.  Malignant  processes  not  rarely  distinguish  themselves  by 
a  rapid  increase. 

5.  Among  the  afebrile  diseases  of  the  abdomen  a  strong  aldehyde 
reaction  is  an  almost  regular  accompaniment  of  acute  enlargement  of  the 
liver  and  of  Laennec's  cirrhosis,  as  long  as  same  progresses  without 
ascites. 

6.  In  cases  of  chronic  congestion  of  the  liver  with  secondary  indura- 
tion, and  in  cases  of  Laennec's  cirrhosis  together  with  ascites,  the  alde- 
hyde reaction  may  occasionally  be  absent  in  the  urine.  With  chronic  in- 
duration of  the  liver  resulting  from  the  proliferation  of  firm  connective 
tissue  the  conditions  might  be  more  unfavorable  for  compression  of  the 
biliary  passages  through  congestion  of  the  blood-channels. 

7.  In  definitely  ascertained  malignant  disease  of  the  abdomen  a  con- 
tinued or  progressive  aldeh^^de  reaction  in  the  urine  becomes  a  decidedly 
important  symptom,  which  will  always  demand  a  most  exact  examination 
of  the  liver ;  it  may  stand  in  relation  to  a  secondary  or  primary  neo- 
plastic disease  of  the  liver  itself  or  to  glandular  affections  about  the 
liver,  providing  there  be  no  complications,  such  as  cirrhosis,  etc.  Still, 
precaution  must  be  exercised,  because  in  just  such  cases  we  may  meet 
with  aldehyde  reaction  even  without  severe  anatomic  disease  of  the  liver. 

8.  The  absence  of  the  aldehyde  reaction  in  the  urine  in  a  case  of 
demonstrable  disease  of  the  liver  is  a  remarkable  finding;  but  it  may 
never  be  used  as  an  argument  against  disease  of  the  liver.  To  what  ex- 
tent an  affection  of  the  liver  gives  rise  to  urobilinogenuria  will  depend  on 
the  degree  of  intrahepatic  biliary  congestion  produced  b}^  the  process. 

9.  As  in  all  qualitative  tests,  the  result  of  the  aldeh3^de  reaction 
should  have  reference  to  the  specific  gravity  and  the  daily  quantity  of 
urine.  In  case  of  poh'uria  with  low  specific  gravity  a  negative  finding 
is  correspondingly  less  weighty,  w^hilst  a  positive  finding  is  correspond- 
ingly more  weighty. 

SYMPTOMATOLOGY    OF    CACHEXIA    AND    GENERAL 

SYMPTOMS 

The  name  "Cachexia"  (from  the  Greek  "y.ay.o;,"  bad,  and  "I^t;," 
to  be  or  to  behave),  which  in  and  of  itself  means  little,  ought  to  he  used 
in  those  cases  only  where  there  is  a  combination  of  general  symptoms, 
namely,  the  trio :  emaciation,  adynamia  and  an  unhealthy  color  of  the 
face. 

With  this  definite  limitation,  cachexia,  even  in  its  early  stages,  be- 

*^  Appearance  of  a  strong  aldehyde  reaction  was  occasionally  observed  by  me  in 
cases  of  pregnancy.  In  view  of  the  frequency  of  postpuerperal  cholelithiasis  it  would 
be  very  desirable  to  institute  repeated  tests  with  the  aldehyde  reaction  during  the 
course  of  pregnancy. 


38  TUMORS    OF    THE    ABDOMINAL    VISCERA 

comes  a  directly  valuable  symptom,  particularly  in  the  diagnosis  of  ab- 
dominal neoplasms,  since  its  limitations  are  logically  essentially  narrower 
than  that  of  its  component  factors.  These  latter  will  now  be  discussed 
separately  as  to  their  significance  in  differential  diagnosis. 

1.  Emaciation 

Emaciation 

Whenever  a  malignant  abdominal  process  enters  the  diagnostic  field, 
the  anamnesis  and  continued  observation  will  keep  sharply  in  view  the 
body- weight.  Occasionally  those  surrounding  the  patient  have  noticed 
the  falling  in  of  the  cheeks,  prominence  of  the  zygomatic  arches,  and  the 
"pointed"  appearance;  the  patient  himself,  who  formerly  had  a  "belly," 
notes  the  looseness  of  his  trousers  and  vest,  women  call  attention  to  the 
fact  that  their  arms  are  becoming  thinner,  that  their  corsets  close  more 
easily.     Rings  that  former!}'  fitted  snugly  have  become  loose. 

Thus  we  can  by  retrospection  inform  ourselves  with  much  certainty 
in  regard  to  emaciation,  that  is,  the  loss  of  flesh  and,  later  on,  of  muscle 
tissue,  providing  the  patients  do  not  present  themselves  with  the  precise 
figures  of  their  weight. 

Weighing 

During  subsequent  observation  it  will  bo  of  the  greatest  importance 
to  watch  the  body-w^eight  at  intervals  of  one  to  two  weeks,  using  a  re- 
liable scale  (Sanatorium,  Apothecary's,  etc.). 

Urinary  analysis  cannot  in  the  least  compare  in  practical  significance 
with  the  clear  and  simple  speech  of  the  scales.  Aside  from  the  fact  that 
the  urinary  analyses,  as  a  rule,  cover  a  period  of  only  twenty-four  hours, 
and  do  not  take  into  consideration  the  loss  of  flesh,  the  figures  of  the 
usual  urinary  analysis  are  therefore  very  problematical,  as  the  X-content 
of  the  food  and  the  N-output  in  the  feces  is  mostly  disregarded. 

The  symptom  of  emaciation  ought  always  to  be  considered  in  relation 
to  the  physical  and  ps^^chical  personality  of  the  patient. 

Mind  and  Emaciation 

There  exist  intimate  relations  between  mind  and  body-weight.  In 
the  case  of  neuropathic  individuals  great  caution  should  be  observed  in 
appraising  the  symptoms  of  emaciation. 

We  arc  all  aware  of  the  considerable  and  rapid  loss  of  weight  in  pa- 
tients suffering  from  progressive  paralysis,  melancholia,  mania,  etc.  But 
even  patients  afflicted  with  simple  "irritable  weakness"  may  show  signs  of 
failing  in  weight,  and  under  the  influence  of  exciting  and  depressing 
mental  affections  there  may  result  considerable  losses  in  weight  in  a 
short  time,  which  losses  disappear  with  the  cessation  of  the  causative 
factors,  so  that  if  we  were  to  represent  this  condition  by  curves  we  would 
get  a  sharp  incline  following  a  sharp  decline.  Occasionally,  however,  it 
may  happen  that  following  such  a  neurotic  crisis  in  weight  there  ensues 
a  permanent  decrease  in  the  body-weight. 

Thus  I  saw  a  patient  in  July,  1905,  whose  weight  up  to  a  short  time 


SYMPTOMATOLOGY    OF    CACHEXIA  39 

previous  luul  been  111  kg-;  ho  luid  lost  J30  kg;  his  attending  physicians 
tlioiight  of  curcinonia  of  the  pancreas. 

Only  recently,  iVIay,  1910,  I  saw  the  patient  again;  aside  from  neu- 
rasthenic complaint  and  arteriosclerosis,  he  is  perfectly  well,  but  his 
weight  has  permanently  come  down  to  74  kg. 

Such  cases  will  the  more  easily  awaken  the  suspicion  of  malignant 
abdominal  disease  if,  as  is  frequently  the  case  with  neurotics,  there  are  at 
the  same  time  gastro-intestinal  symptoms,  such  as  anorexia,  gastralgia, 
etc.  In  these  cases  the  cause  of  the  emaciation  frequently  lies  in  under- 
nutrition, be  it  because  the  patient  restricts  his  diet  and  makes  it  mo- 
notonous for  fear  of  trouble,  or  because  he  has  had  prescribed  for  him 
by  his  physician  a  very  restricted  diet  on  the  strength  of  the  erroneous 
diagnosis  of  gastric  ulcer.  On  account  of  under-nutrition,  however,  the 
"irritable  weakness"  of  the  nervous  system  increases,  and  this  condition 
gives  rise  to  the  symptoms  which  complete  the  vicious  circle. 

In  such  cases  a  single  examination  often  makes  it  really  difficult  to  ex- 
clude malignant  disease,  and  if  the  patient  notices  any  such  suspicion 
from  the  actions  of  the  physician  or  his  own  surroundings,  then  the  basis 
for  a  new  aggravation  of  his  general  nervous  condition  is  established. 

Here  it  is  often  most  desirable  to  simply  ask  "therapeutic  questions." 

After  occult  hemorrhages  have  been  ruled  out,  the  patient  should  be 
treated  as  a  neurasthenic,  he  should  be  told  to  abstain  from  work  and  be 
removed  from  his  uneasy  surroundings ;  place  him  in  a  favorable  climate 
and  on  a  favorable  diet,  discontinue  the  solicitous  regime  of  diet,  and 
frequently  in  two  to  three  weeks  the  patient  will  be  on  the  road  to 
recovery. 

Hence,  in  making  estimation  of  the  diagnostic  value  of  the  symptom 
of  emaciation  the  state  of  the  mind  and  immediate  circumstances,  sucTi 
as  care,  excitement,  etc.,  deserve  full  consideration. 

The  more  forceful  the  personality,  the  smaller  will  be  the  chances  for 
unpleasant  psychic  emotions,  and  the  greater  will  have  to  be  the  valua- 
tion of  emaciation  existing  in  a  given  case. 

The  psychical  side  of  the  patient's  personality  is  to  be  considered, 
especially  in  so  far  as  it  is  not  indifferent  whether  the  supposed  malig- 
nant disease  is  lodged  in  an  individual  with  little,  or  in  one  with  much, 
adipose  tissue.  In  the  latter  case  emaciation  is  more  conspicuous  and 
is  made  much  more  explicit  by  actual  figures. 

Accordingly,  the  initial  losses  in  weight  are  often  more  considerable; 
if  the  body-weight  has  already  dropped  very  much,  it  usually  diminishes, 
not  suddenly  but  gradually. 

Increase  in  Weight 

Here  I  may  note  with  emphasis  that  weight  increases  not  due  to  mere 
retention  of  fluids  such  as  take  place  in  hydrops  or  anasarca,  but  real 
increases  from  the  addition  of  fat  and  muscle  tissue  may  occasionall}' 
be  observed  in  the  course  of  malignant  diseases  of  the  abdomen.  This 
can  be  easily  understood  if  one  keeps  in  view  the  general  pathogenesis 
of  emaciation  in  malignant  diseases. 


40  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Pathogenesis  of  Emaciation 

In  the  vast  majority  of  cases  the  pathogenesis  ultimately  rests  on 
disturbances  in  assimilation,  which  in  their  turn  depend  in  a  large  measure 
on  disorders  of  "external"  digestion  in  the  gastro-intestinal  tract.  In 
almost  all  cases  of  emaciation  macroscopic  or  microscopic  examination 
reveals  the  fact  that  the  food  has  been  but  poorly  used  up,  there  being 
present  an  abundance  of  muscle  fibres,  soaps,  neutral  fat,  etc.  The  fre- 
quent worrying  losses  in  weight  that  occur  with  benignant  forms  of  jaun- 
dice are  remarkable. 

The  influence  on  "internal  digestion,"  which  undoubtedly  is  at  the 
bottom  of  the  emaciation  in  certain  forms  of  diabetes  mellitus,  and  which 
is  employed  in  accounting  for  the  emaciation  that  follows  administration 
of  thyroid  gland  substance,  acute  infectious  diseases,  etc.,  could  hardly 
be  considered  as  playing  a  real  part  in  cancerous  diseases. 

Whoever  has  observed  even  once  how  rapidly  the  weight  increases 
after  a  simple  gastro-enterostomy  in  cases  of  stenosing  pyloric  cancers — 
without  removing  the  neoplasm — will  hardly  venture  to  ascribe  the  pre- 
ceding emaciation  to  hypothetical  cancer  toxins. 

Even  otherwise  it  is  not  difficult  to  realize  that  the  emaciation  de- 
pends above  all  on  the  relation  of  the  new  growth  to  the  digestive  tract. 
Tims  it  happens  that  occasionally  cancer  of  the  uterus,  breasts,  kidneys, 
etc.,  run  along  with  the  external  appearance  of  blooming  health. 

And  from  this  point  of  view  it  can  be  well  comprehended  why  within 
the  digestive  tract  carcinoma  of  the  rectum  most  frequently  is  accom- 
panied by  a  good  state  of  nutrition. 

Besides  direct  local  functional  disturbance  and  its  general  effects  on 
the  entire  digestive  tract,  it  is  found  that  precisely  with  malignant  new- 
growths  inside  of  the  chylef active  system  it  is  largely  the  ulcerative 
process  which  considerably  hastens  the  process  of  emaciation  through 
chronic  loss  of  body  fluids,  absorption  of  rotten  disintegrated  tissue  mat- 
ter and  septic  infections. 

Excluding  a  specific  toxic  cause  of  emaciation,  after  what  has  been 
said  it  must  at  once  become  apparent  that  even  in  cases  of  malignant 
new-growths  increases  in  weight  can  be  brought  about  in  such  cases 
where  rest — rest  in  bed — takes  the  place  of  occupational  exertion,  be  it 
physical  or  mental,  where  a  suitable  dietetic  regime  is  chosen  and  where 
the  effort  is  made  to  readjust  functional  disturbances  by  physical  and 
medicinal  means. 

However,  it  must  be  emphasized  that  these  gains  in  weight  stay  Avithin 
moderate  limits  and  mostly  represent  a  rapidly  transient  occurrence. 

2.  Color  of  the  Face  and  Pigment  Anomalies 

Among  the  integral  distinguishing  signs  of  the  cachexia  found  in  con- 
nection with  malignant  neoplasms  we  count  alterations  in  the  color  of  the 
face,  which,  at  times,  are  the  first  indication  of  a  malignant  disease. 

Before  all,  we  should  give  consideration  to  the  "teint  paille  jaune," 
that  light  yellow  discoloration   of  the  face  which  is  perhaps   most   fre- 


SYMPTOMATOLOGY    OF    CACHEXIA  41 

quently  found  with  cancer  of  the  stomach.  Despite  its  yellow  tint,  it 
has  not  the  least  in  common  with  icterus,  and  in  numerous  cases  in  which 
I  examined  the  urine  I  found  neither  bilirubin  nor  urobilinogen.  It  is 
possible  that  we  are  here  dealing  with  a  deposit  of  some  derivative  from 
the  blood  coloring  matter  similar  to  deposits  not  infrequently  found  in 
internal  organs  in  connection  with  various  dyscrasias.' 

While,  on  the  one  hand,  this  "straw-colored"  tint  in  question  is  found 
in  only  a  small  percentage  of  malignant  neoplasms,  we  also  find  it  with 
non-malignant  processes,  as  in  severe  cases  of  tuberculosis,  chronic  puru- 
lent conditions,  and  especially  in  processes  that  incline  to  amyloidosis. 
The  complexion,  in  pernicious  anemia,  too  offen  is  in  perfect  accord  with 
the  above.  In  spite  of  this,  it  would  be  wrong  to  look  for  the  cause  of 
this  peculiar  color  in  the  physical  changes  of  the  blood  only,  since  car- 
cinoma, with  "straw-colored"  face  discoloration,  often  yields  almost  nor- 
mal blood  findings.  Chloranemic  findings  also  are  not  rare.  Ulcerating 
gastro-intestinal  carcinomata  probably  most  often  lead  to  the  peculiar 
complexion  in  question. 

Paleness 

The  already  mentioned  incongruity  between  the  complexion  and 
blood  findings  applies  also  to  those  more  frequent  cases  of  malignant  tu- 
mors, which  are  accompanied  by  a  light-gray  paleness  of  the  countenance. 

In  these  cases  the  blood  picture  shows  nearly  normal  conditions,  par- 
ticularly as  far  as  the  coloring  power  of  the  blood  is  concerned. 

In  cases  of  this  kind,  w^eakness  of  the  peripheral  circulation  ^"^  might 
be  looked  upon  as  the  cause  of  facial  paleness,  similarly  in  some  cases  of 
asthenic  constitution  and  certain  forms  of  arteriosclerosis  (lues!)  and 
in  tabes.  The  acute  peripheral  circulatory  weakness  and  poor  per- 
meability of  the  blood  in  fainting  spells  has,  to  a  certain  extent,  been 
permanently  explained. 

As  the  color  of  the  face  is  an  integral  component  part  of  the  con- 
stitutional peculiarity  of  every  individual,  and  as  already  mentioned,  cer- 
tain constitutions  are  noted  for  their  pale  countenances  even  when  in 
perfect  health,  the  anamnesis  will  have  to  allow  for  this  fact  when  there 
is  suspicion  of  cancer.  In  most  cases,  the  women-folk  will  be  able  to 
offer  the  best  information  in  regard  to  any  changes  in  the  appearance  of 
the  patient. 

This  individual  characteristic  also  deserves  consideration,  in  so  far  as 
certain  individuals,  especially  those  of  asthenic  neuropathic  constitu- 
tions, who  are  frail  of  countenance  and  who  easily  collapse,  are  concerned. 

On  the  contrary,  there  are  powerful  constitutions  inclined  to  plethora, 
that  occasionally  show  a  healthy  red  color  of  the  face,  even  with  ad- 
vanced malignant  disease. 

The  cachectic  color  of  the  face  seems  to  be  absent  most  frequently  in 
cases  of  non-ulcerating  neoplasms,  such  as  primary  cancer  of  the  liver, 

melanocarcinoma,  carcinoma  of  the  pancreas,  etc. 

^ « — ■ — — — — - — 

"  In  this  respect,  regard  must  be  had  for  the  capillary  dilatations  so  frequently 
seen  on  the  cheeks  'of  cancer  patients  and  probably  due  to  arteriosclerosis. 


42  TUMORS    OF    THE    ABDOMINAL    MSCERA 

Figment  Anomalies 

With  the  color  of  the  face,  peculiar  to  individuals,  there  sometimes 
are  associated  other  pigment  anomalies  of  the  skin,  especially  Addison- 
like  discolorations.  In  these  cases  we  must  be  on  our  guard  against  a 
too  hasty  diagnosis  of  suprarenal  disease,  be  it  primary  or  secondary. 
Whoever  has  in  mind  to  demonstrate  a  lesion  of  the  suprarenal  bodies  at 
autopsy  may  often  succeed,  in  so  far  as  metastases  in  these  organs,  cal- 
lous induration  of  same,  etc.,  are  not  rare  in  connection  with  malignant 
new-growths  of  the  abdomen.  Yet  we  often  enough  find  these  pigmenta- 
tions when  the  suprarenals  are  completely  intact.  There  are  three  sepa- 
rate possibilities  that  must  be  considered  here: 

a.  The  pigmentations  similar  to  Addison  discoloration,  at  times  seg- 
mentall}''  arranged  on  the  trunk  alongside  of  depigmented  areas,  are  pre- 
existent,  and  date  back  many  years,  even  as  far  as  childhood.  As  in 
pernicious  anemia,  so  also  with  malignant  neoplasms,  they  are  to  be 
considered  as  a  constitutional  stigma.  In  most  of  these  cases  we  are 
dealing  with  asthenic  constitutions,  and  in  some  families  such  occurrences 
are  frequently  observed. 

b.  The  pigmentations  may  be  synchronous  with  the  development  of 
carcinoma,  and  are  to  be  looked  at  as  a  hemochromatosis  of  Reckling- 
hausen. Its  appearance  seems  to  be  favored  by  an  abundance  of  pigment 
in  dark-haired  individuals,  with  darkly  pigmented  iris  and  dark  com- 
plexion, as  well  as  by  factors  which  in  and  of  themselves  induce  hyper- 
pigmentation,  such  as  strong  sunlight  when  working  in  the  fields,  etc. 

Carcinoma  of  the  pancreas  is  among  the  neoplasms  most  frequently 
accompanied  by  pigmentation  of  the  skin. 

To  this  group  there  probably  also  belong  those  skin  discolorations 
occasionally  observed  in  severe  pulmonary  tuberculosis  or  in  splenomegaly 
as  a  result  of  chronic  splenic  tuberculosis,  in  which  cases  we  may  be  in- 
clined to  agree  with  v.  Netisser  in  assuming  toxic  injuries  to  the  sympa- 
thetic nervous  system  as  being  the  cause. 

c.  With  combined  high  urobilinogen  content  in  the  urine,  as,  for  in- 
stance, in  liver  metastases  and  cirrhotic  complication,  it  would  be  proper 
to  take  into  consideration  whether  the  hyperpigmentation  of  the  skin 
might  not,  at  least  in  part,  have  some  connection  with  the  rich  urobili- 
noe-en  content  of  the  tissue  fluids. 


3.     Adynamia 

Adynamia 

All  other  things  being  equal,  this  symptom  will  appear  earlier  and 
more  pronouncedly  in  asthenic  constitutions  and  vice  versa  manifest 
itself  late  in  stronger  constitutions.  In  man^'  cases  it  will  be  judicious  to 
make  a  functional  test  by  trying  out  the  patient's  ability  to  perform 
certain  regulated  amounts  of  work.  , 

Adynamia  shows  itself,  for  that  matter,  not  only  in  general  fatigue 
but  also  in  a  lowering  of  circulatory  force. 


SYMPTOMATOLOGY    OF    CACHEXIA  43 

Edema 

This  at  least  is  one  of  the  M^ays  in  which  the  occurrence  of  edemas 
comes  about,  and  these — after  exchision  of  cardioreual  disease — become 
of  considerable  diagnostic  import. 

\yhenever  there  is  suspicion  of  malignant  neoplasm  of  the  abdomen, 
one  should  never  neglect  to  examine  the  space  behind  the  internal  mal- 
leolus b}'  making  pressure  on  it  with  the  finger.  In  malignant  disease 
edema  is  often  encountered  in  this  place,  even  though  the  tibias  are 
entirely  free  from  it. 

Examination  over  the  os  sacrum  is  equally  important — especially  in 
bedridden  patients  in  whom  mild  edemas  around  the  ankles  easily  dis- 
appear. 

Latent  Edema 

Latent  edemas,  such  as  have  disappeared  with  rest  in  bed  or  such  as 
have  not  yet  made  their  appeai-ance,  may,  according  to  my  own  observa- 
tions, be  elicited  by  means  of  a  hot  foot-bath. 

We  can  find  all  stages  of  transition  from  dropsical  swellings  of  high 
degree  that  appear  early,  and  present  the  picture  of  a  severe  parenchy- 
matous nephritis,  to  the  other  extreme,  namely,  that  of  mummification. 
In  one  place  shrinkage,  in  the  other  swelling. 

In  general,  it  may  be  said  that  soft,  strongly  ulcerating  and  bleeding 
neoplasms,  like  medullary  cancer  of  the  stomach,  lymphosarcoma  of  the 
small  intestine,  etc.,  frequently  lead  to  severe  dropsies. 

With  fibrous  forms  of  carcinoma  (gall-bladder,  pylorus,  etc.), 
edemas  are,  from  general  causes,  much  less  frequent,  and  stomach  can- 
cers which,  on  account  of  severe  pyloric  stenosis  or  diffuse  contraction  of 
the  stomach,  cause  frequent  vomiting,  at  times  lead  to  progressive  exsic- 
cation of  the  tissues. 

In  this  edema  and  ascites  may  again  disappear. 

In  no  case  and  in  no  stage  might  the  absence  of  edema  be  construed 
as  an  argument  against  a  malignant  growth ;  so  it  happens  that  occa- 
sionally enormous  liver  metastases  run  their  course  without  even  a  trace 
of  edema. 

It  is  certain  also  that  in  these  combinations  the  individual  peculiari- 
ties of  the  skin  and  the  subcutaneous  connective  tissue  play  a  part.  The 
softer  and  more  succulent  the  skin,  the  easier  there  will  occur  in  it  ac- 
cumulations of  fluid;  the  tenser  and  dryer  it  is  (extremes  of  this  would 
be  cases  of  congenital  icthyosis),  the  less  will  be  the  tendency  to  edema- 
tous swellings. 

Congestion  from  Local  Causes 

Besides  the  edemas  due  to  general  weakness  of  the  peripheral  circu- 
lation, or  to  a  general  dyscrasia,  there  also  frequently  exist  in  cases  of 
abdominal  neoplasms  local  causes  for  dropsical  engorgement,  and  they 
give  rise  mostly  to  edema  of  one  leg,  hence  dii*ect  compression  of  the 
venous  trunks,  thrombosis  and  rupture  into  the  venous  channel. 


44.  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Body  Temperature 

Variations  from  the  normal  temperature  of  the  body  are  to  be  met 
with  frequently  in  connection  with  abdominal  neoplasms. 

As  far  as  subnormal  tempei*atures  of  36°  C,  and  even  less,  are  con- 
cerned, they  are  of  little  diagnostic  interest,  since  they  are  only  a  par- 
tial expression  of  the  general  cachectic  lowering  of  the  vital  energy. 

Far  more  interest  attaches  to  elevations  in  body  temperature,  though, 
generally  speaking,  the  lowest  level  of  the  fever  curve  in  cachectic  sub- 
jects naturally  possesses  lower  diagnostic  value.  Personally,  I  do  not 
consider  that  it  has  been  proved  that  there  is  a  specific  fever,  i.e.,  a  fever 
emanating  from  the  activity  of  the  tumor  cells. 

The  frequency  scale  of  febrile  phenomena,  with  reference  to  the  type 
and  seat  of  the  neoplasm,  favors  the  view,  that  we  are  dealing  with  a 
secondary  infection. ^^ 

Thus  medullary  ulcerating  forms  of  gall-bladder  cancer,  not  infre- 
quently, run  their  course  with  fever,  at  times  accompanied  by  herpes 
and  a  mild  diazo  reaction ;  the  same  is  true  of  duodenal  carcinoma  with 
which  ascending  infections  of  the  bile-passages  can  easily  take  place. 
Cholecystitis  and  cholangitis  or  cholangitic  abscesses  are  the  original  un- 
derlying factors  of  the  fever  that  is  seen  with  intra-hepatic  malignant 
processes. 

In  ulcerating  forms  also  of  stomach  and  bowel  cancer  there  is  plen- 
tiful access  for  the  exciting  agents  of  infection  and,  indeed,  it  is  sur- 
prising that  febrile  temperature-rises  occur  singly  and  sporadically,  and 
are  of  such  mild  degree. 

Here,  also,  we  are  concerned  with  complications  such  as  perigastric, 
subphrenic  or  pericolitic  purulent  foci,  especially  when  the  febrile  move- 
ments continue  over  a  longer  period  of  time. 

Complicating  infectious  processes  may  thus  occur  and  give  rise  to 
chills,  which,  however,  are  mostly  isolated,  or  follow  each  other  at  longer 
and  irregular  intervals. 

When  they  are  accompanied  by  severe  collapse,  there  will  always  en- 
ter into  serious  diagnostic  consideration  the  possibility  of  a  beginning 
peritonitis  due  to  perforation.  Aside  from  this,  chills  may;  according  to 
my  own  observation,  result  from  internal  hemorrhage  in  cases  of  car- 
cinoma of  the  stomach. 

If  the  febrile  rises  in  temperature  are  accompanied  by  night-sweats, 
which  occasionally  is  the  case  in  connection  wdth  malignant  abdominal 
tumors,  there  might  arise  the  false  suspicion  of  a  tubercular  process, 
especially  when  supported  by  an  occasional  diazo  reaction. 

From  what  has  been  said  we  may  deduce  two  diagnostic  rules  which 
are  not  unimportant : 

1.  With  obscure  febrile  conditions  in  older  individuals  the  possibility 
of  malignant  new-growths,  especially  of  the  gastro-intestinal  tract,  should 
not  be  forgotten. 

*"'  In  regard  to  similar  and  opposite  \iews,  see  F.  Fromme,  Deutsche  med.  W., 
1907,  No.  14;  A.  Alexander,  Deutsche  med.  W.,  1907,  No.  5. 


ETIOLOGY    OF    MALIGNANT    TUMORS  45 

2.  In  the  diagnosis  of  cases  that  give  the  suspicion  of  stomach  or 
intestinal  cancer,  do  not  fail  to  give  attention  to  the  behavior  of  the 
bod>^  temperature ;  in  the  differential  diagnosis  from  chronic  catarrhal 
conditions  elevations  in  temperature  may  occasionally  merit  serious  con- 
sideration and,  under  circumstances,  may  argue  in  favor  of  a  malignant 
ulcerative  process. 

ETIOLOGY    OF    MALIGNANT    TUMORS 

In  their  ultimate  causes  all  processes  of  growth  are  traced  back  to, 
and  become  merged  with,  the  problem  of  life  itself,  and  will  therefore  re- 
main problematic  to  scientific  research  which  is  based  on  sensible  per- 
ception ;  indeed,  when  considered  with  reference  to  their  final  causes  they 
are  no  longer  a  problem  of  natural  science  but  of  metaphysics. 

It  is  a  psychologically  easily  explainable  characteristic  of  etiological 
research  that  in  dealing  with  disease  processes  there  is  a  tendency  to  trace 
a  morbid  condition  to  one  single  cause,  as  in  ctiologically  tracing  syphilis 
we  justly  lay  it  to  the  entrance  of  the  spirocheta  pallida  of  SchaiuVinn. 

This  tendency  was  nurtured  above  all  by  the  brilliant  results  of  bac- 
teriological research  and  its  establishment  of  specific  causes  for  disease, 
without  the  effects  of  which  a  given  disease  is  not  conceivable.  If  ever 
such  an  interpretation  of  a  single  cause  can  claim  practical  title  it  cer- 
tainly can  do  so  in  the  realm  of  infectious  diseases. 

Yet,  even  in  this  domain  the  conviction  is  always  gaining  more  ground 
that,  in  a  pathological  occurrence,  besides  the  one  specific  cause,  i.e.,  the 
infectious  excitant,  many  other  factors,  e.g.,  of  a  constitvitional  type, 
come  into  play. 

In  a  philosophical  sense  there  is  really  no  uniform  cause  of  a  "hap- 
pening," every  cause  being  at  the  same  time  an  effect. 

Though  such  foresightedness  in  every  single  case  would  be  imma- 
terial and  useless,  I  feel  justified  in  warning  against  the  other  extreme  of 
too  great  nearsightedness. 

Three  factors  are  especially  significant  in  the  causative  perception  of 
disease  processes : 

1.  That  more  frequently  they  do  not  have  specific  causes  than  that 
they  do  have  them. 

2.  That  the  causes  decidedly  do  not  always  correspond  to  the  pres- 
ent time  of  the  pathological  process,  but  occasionalh^  date  very  far  back, 
as  the  single  individual  is  nothing  exclusive  in  himself,  but,  merely  rep- 
resents the  latest  link  in  the  chain  of  his  ancestors. 

3.  That  accordingly  the  causes  of  disease,  or  at  least  a  part  of  them, 
ought  not  always  to  be  sought  after  in  the  external  world,  but  in  many 
ways  also  in  the  internal  world  of  living  matter. 

4.  That  strict  distinction  is  to  be  made  between  a  specific  cause  of 
disease,  without  which  the  disease  process  in  question  is  inconceivable, 
and  non-specific  causative  factors,  which  at  times  may  act  against  and 
represent  one  another  and  very  often  prodifce  effects  only  through  being 
combined  in  manifold  groupings.  * 


46  TUMORS    OF    THE    ABDOMINAL    VISCERA 

As  pathological  processes  of  cell-proliferation,  at  least  in  their  ele- 
mentary causes,  certainly  have  points  of  contact  amongst  themselves 
as  well  as  with  physiological  processes  of  growth,  a  consideration  of 
them  in  these  wider  limits  can  only  favor  an  understanding  of  the  genesis 
of  malignant  processes  of  growth. 

Ovum 

That  which,  to  us,  is  the  greatest  riddle  in  this  domain,  is  quite  self- 
evident — the  development  of  the  ovum,  according  to  a  definite  plan,  into 
a  completed  organism  after  fecundation  by  the  spermatozoon. 

If  the  spermatozoon  be  here  considered  as  the  cause  of  the  l>egin- 
ning  cell-proliferation  one  will  be  satisfied  that  it  is  a  cause  which  cannot 
measure  up  with  the  effect,  since,  doubtless,  the  ovum  possesses  an  innate 
force  which  as  a  cause  comes  much  more  into  consideration. 

An  infinitely  complicated  machinery  which,  as  if  through  removal  of 
some  restraint,  runs  along  as  if  conscious  of  its  destination. 

Fecundation  Theory  of  Klehs 
and    Others 

The  physiological  example  of  the  fecundated  ovum  has  led  to  the 
fantastic  cancer  theory  of  Klehs — a  theory  now  largely  forsaken — 
according  to  wliich  epitlielial  cells  are  fecundated  by  the  entrance  of 
leucocytes. 

Full  consideration  is  due  the  enormous  power  of  division  belonging  to 
the  ovum,  and  which,  as  an  elementary  property,  is  transmitted  to  the 
descendant  cells  in  varying  degree  and  according  to  the  need  for  cell- 
replacement. 

Internal  Secretion  Groivth 

Very  remarkable  are  the  manifold  relations  of  glands  with  internal 
secretion  and  processes   of  cell-multiplication   and  cell-growth. 

The  shedding  and  growths  of  horns  in  cervides,  the  enlargement  of 
the  breasts  during  pregnancy,  the  changes  in  acromegaly,  etc.,  are 
throughout  processes  of  growth  which  are  undoubtedly  at  least  elicited 
by  the  entry  of  certain  products  of  internal  secretion  into  the  circula- 
tion, since  here  also  we  can  assume  as  cause  a  latent  proliferative  ability 
residing  in  the  growing  cells  themselves,  and  that  in  accordance  with  a 
definite  plan  of  construction.  Here,  also,  belong  the  relations  of  the 
thyroid  gland  to  the  skeletal  system. 

Diatheses 

This  group  of  observations  seems  to  me  to  caution  against  denying 
a  priori  that  the  development  of  neoplastic  processes  is  influenced  by 
eventual  alterations  in  the  bulk  of  body  fluids  giving  rise  to  certain 
diatheses  (gout,  diabetes,  etc.). 

The  gross  errors  of  the  old  humoral  pathology  in  regard  to  the  gene- 
sis of  cancer  have  led  to  a  inaction  which  in  its  denial  of  the  influences 
of  dyscrasias  probably  goes  beyond  the  bounds  of  truth. 


ETIOLOGY    OF    MALIGNANT    TUMORS  47 

Exogenous  Injuries  Exciting 
Inflammation 

Moreover,  all  those  chiefly  exogenous  injuries  which  are  al^le  to  excite 
inflannnation  have  an  influence  in  eliciting  cell-proliferation. 

Beginning  with  the  mechanical  injury  of  a  pressing  shoe,  and  pass- 
ing (iver  soot,  paraffin,  etc.,  to  the  spirocheta  pallida  of  Schaudinn  and 
the  X-rays,  there  is  an  infinite  number  of  special  causes.  This  group  of 
biological  irritants  is  undoubtedly  most  intimately  related  to  the  genesis 
of  cancer,  even  if  they  are  not  considered  as  specific  causes,  and  their 
operation  in  eliciting  malignant  cell-proliferations  can  be  assumed  only 
through  their  combination  with  other  causative  factors,  particularly 
those  of  an  endogenous  nature.  Finally,  Ave  nuist  be  mindful  of  those 
processes  of  growth  which  result  from  increased  functional  demands,  as 
when  a  muscle  is  made  to  do  more  work. 


In  the  formation  of  an  opinion  as  to  the  genesis  of  malignant  tumors 
two  points  of  view  seem  to  me  very  worthy  of  note. 

1.  The  circumstance  that  malignancy  in  many  ways  is,  as  it  were, 
superimposed  on  a  benign  tumor.  Therefore,  it  will  hardly  do  to  pre- 
sume that  there  are  totally  different  kinds  of  origin  for  benignant  and 
malignant  new-grow'ths,  hence,  also,  the  study  of  tumor-formations  with 
reference  to  the  etiology  should  really  begin  with  the  benignant  forms 
which  frequently  are  the  first  steps  of  the  malignant  ones. 

2.  The  probability  of  a  tumor  theory  must  rest  on  the  hypothesis 
that  it  does  not  apply  to  epithelial  grow^ths  alone,  but  will  also  be  able 
to  explain  the  malignant  connective-tissue  growths,  the  more  so,  as  even 
here  transitions  seem  to  occur. 


Comparable  to  a  nihilistic  attempt  against  the  stability  of  the  state, 
malignant  tumors  offer  occasion : 

1.  To  deal  with  the  person  who  makes  the  attempt,  that  is,  definite 
cell-groups  or  areas  of  organs  from  which  the  growth  originates,  and, 
furthermore : 

2.  To  search  for  those  influences  which  led  to  the  attempt,  at  times 
converting  a  normal  citizen  into  a  pathological  criminal. 

I.  Cell  Disposition  • 

CeU  Disposition 
Cohnheim's   Theo ry 

Many  of  the  theories  that  endeavor  to  explain  the  genesis  of  ma- 
lignant new-growths,  really  limit  themselves  to  making  plausible  some 
local  cell  disposition,  thus,  especially,  Cohnheim-'s  theory  of  embryonic 
displacement  of  cells. 

Resuming  the  former  comparison:  The  nihilistic  criminal  probably 
is  bom  a  criminal,  he  is  a  degenerated  individual  abnormally  disposed 
from  his  birth. 


48  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Similarly,  we  are  inclined  to  consider  those  cell-groups,  from  which 
malignant  new-growths  are  developed,  as  being  abnormally  disposed  from 
the  start,  having  remained  and  become  degenerated  in  an  earlier  stage  of 
development ;  still,  it  is  also  possible  that  long-continued  external  in- 
juries, through  their  influence,  may  generate  a  state  of  depravity,  and 
that  the  more  easily,  of  course,  when  they  find  their  point  of  attack  in 
individual  cells  which  are  ali-ead^^  abnormal  or  which  were  originally  of 
low  grade  and  little  differentiated. 

There  is  no  doubt  that,  as  far  as  the  origin  of  certain  malignant  new- 
growths  is  concerned,  we  are  actually  dealing  with  displaced  embryonal 
cells.  This  is  particularly  true  of  the  kidney  tumors  of  Grawitz,  der- 
moids, certain  retroperitoneal  swelling  formations,  emanating  from  rests 
of  the  Wolffian  bodies,  etc. 

Precisely  this  group  of  malignant  neoplasms  are  the  most  striking 
argument  against  the  parasitic  theory  of  cancer  genesis. ^"^  We  are  to 
believe  that  the  cancer  excitants,  as  if  by  selection,  will  produce  their 
effects  from  the  blood-current  and  leave  intact  all  other  tissue-cells. 

Even  here,  for  that  matter — with  reference  to  the  displaced  cells — 
we  are  not  dealing  with  a  sine  qua  non,  with  no  essential  or  even  specific 
cause.  Otherwise,  for  instance,  it  would  be  entirely  inconceivable  why 
carcinoma  of  the  small  intestine  should  be  so  extremely  rare  in  compari- 
son to  carcinoma  of  the  stomach,  as  if  scarcely  any  displaced  cells  should 
be  at  hand.  Perhaps,  there  is  hardly  an  individual  who  does  not  have 
somewhere  in  his  anatomy  embryonic  displaced  cell-masses  (n.-Evi,  etc.). 
This  point  alone  is  therefore  surely  not  a  sufficient  explanation. 

Cohnheim's  theory  probably  rests  upon  the  consideration  that  it  is 
difficult  to  imagine  how  highly  differentiated  cells  can  sink  to  such  a  low 
biological  state  and  become  so  estranged  from  the  entire  organism,  as  is 
true  of  the  anarchistic  malignant  tumor-cells. 

One  way  to  evade  this  difficulty  would  be  by  assuming  that  the  tumor 
does  not  originate  from  the  fully  differentiated  cells  but  from  germinal 
centres  {Schaper's  Indifference  Zones),'*"  which  are  composed  of  cells  that 
are  imperfectly  differentiated  and  approaching  more  the  embryonic 
state. 

Rihhert's  Theory 

Equally  unsatisfactory  is  Ribherfs  theory  of  post-fetal  epithelial 
displacements  brought  about  b3'  chronic  inflammation  in  connective  tissue. 

It  must  jcertainly  be  granted  that  cell-masses  thus  injured  and  grow- 
ing under  abnormal  conditions  of  life  may  occasionally  become  the  point 
of  origin  of  new-growths.  The  disposition  of  the  cells  to  malignancy 
may  in  some  cases  be  in  part  actually  conditioned  by  their  topographical 
and  functional  separation  from  the  normal  cell-connection. 

Certainly  there  is  justification  for  the  theory — and  it  is  supported 

^^See:  Umfrage  iiber  Aetiologie  des  Carcinoma,  Med.  Klinik,  1905,  page  409,  496, 
544.       Aiisserungen  von  L.  Aschoff,  E.  Ziegler,  Marchand. 

"  Schaper  and  Cohen,  Beitrage  zur  Anatomic  des  tierischen  Wachstums.  Arch.  f. 
Entwickelungsmechanik,   XIX,   3,   1905. 


ETIOLOGY    OF    MALIGNANT    TUMORS  49 

bj  histological  findings — that  without  such  anatomical  displacement 
chronic  irritation  may  lead  to  a  loss  of  higher  cell-functions,  may  pro- 
duce a  disturbance  in  the  functional  equilibrium  of  the  cell,  and  thus 
bring  about  the  appearance  of  the  most  original  function  of  the  cell, 
namely,  its  ability  to  divide. 

Hansemann's  Anaplasia 

In  his  doctrine  of  "anaplasia"  of  cancer-cells,  v.  Hansemann  has  tried 
partly  to  furnish  anatomical  foundation  for  this  view  of  cell-depravity. 

II.  Etiology  in  its  Narrower  Sense 

Etiolorjy  in  Its  Narrower  Sense 

As  all  probability  seems  to  point  against  the  assumption  of  a  specific 
cause  in  the  nature  of  a  microbe  for  malignant  neoplasms,  the  causative 
relations  Avill  have  to  be  investigated  from  case  to  case. 

Here,  then,  we  will  again  have  to  consider  (a)  endogenous  factors  as 
well  as  (b)  exogenous  irritants.  , 

a.  Endogenous  Causes 

Endogenous  Causes 

Changes  in  the  organism  due  to  age  count  among  the  most  apparent 
factors  in  this  domain.  Even  though  malignant  proliferative  processes 
may  occur  congenitally  or  take  place  during  the  years  of  development, 
their  relations  to  a  more  mature  age  are  well  knowTi  and  justify  our 
speaking  of  cancer  as  a  disease  of  advanced  years.  This  is  a  peculiarity 
which  does  not  apply  to  a  single  one  of  the  many  known  infectious 
processes  and  therefore  serves  as  another  argument  against  the  parasitic 
theory  of  cancer. 

Age 

Of  what  kind  arc  the  elementary  relations  between  age  and  malignant 
new- growths  ? 

Disturbances  in  the  plan  of  construction  which  from  the  constant 
changing  of  cells  can  be  assumed  to  exist  also  in  post-embryonic  life, 
are  surely  conceivable  in  view  of  the  unequally  rapid  aging  of  the  differ- 
ent tissues,  e.g.,  epithelium  and  connective  tissue.  On  this  is  based  the 
theory  of  Thiersch,  who  supposes  a  disturbance  of  the  static  equilibrium 
between  epithelium  and  stroma  as  a  predisposing  factor  in  the  develop- 
ment of  cancer. 

It  may  also  seem  exceedingly  plausible  to  assume  that  in  more  ad- 
vanced age,  under  the  influence  of  local  circulatory  disturbance,  cell- 
complexes  may  at  times  degenerate,  thereby  losing  their  higher  charac- 
teristic properties,  and  instead  there  comes  to  the  fore,  unhindered,  a 
tendency — corresponding  to  an  elementary  function — to  multiply,  be- 
ing, as  it  w^ere,  an  "irritable  weakness." 

But  also  alterations  in  the  metabolic  processes  of  the  entire  organism 
enter  into  consideration. 


50  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Be  that  as  it  may,  changes  in  age  undoubtedly  figure  as  a  causative 
factor  in  the  genesis  of  carcinomatous  new-growths  in  particular.  Ma- 
lignant proliferative  changes  here  go  hand  in  hand  with  benign  ones, 
especially  so  in  the  aging  skin,  and  point  to  a  common  causative  source. 

Attention  may  here  be  called  to  those  tiny  angiomatous  formations 
of  the  skin,  which,  as  a  general  thing,  first  appear  more  numei'ousl}-  in 
old  age  and  have  been  pointed  out,  erroneously,  as  marks  of  malignant 
new  formations.^*  Still,  it  is  a  remarkable  fact  that  in  advanced  years 
the  skin  does  incline  to  manifold  benign  proliferative  processes. 

Constitution  and  Cancer  of  the  Stomach 

With  reference  to  constitutional  peculiarity,  I  would  like  to  sum- 
marize my  own  personal  views,  at  least  so  far  as  the  most  frequent  in- 
ternal neoplasm — cancer  of  the  stomach — is  concerned.  1.  As  far  as 
cases  in  advanced  age  are  concerned  they  are  mostly  individuals  of  very 
robust  constitution,  who  were  "never  sick,"  have  had  but  little  if  any  in- 
fectious disease,  have  never  been  troubled  with  disturbances  of  digestion, 
and,  in  most  instances,  come  from  very  healthy,  long-lived  parents.  They 
are,  in  many  ways,  individuals  in  whose  cases  one  would  be  tempted  to 
speak  of  "excessive  well  being,"  which,  for  that  matter,  may  amount  to  a 
cause,  owing  to  the  fact  that  such  persons  are  able  to  expose  themselves 
much  more  to  dietetic  indiscriminations  witliout  liarmful  results  for  a  long 
time.  2.  As  far  as  younger  people  arc  concerned,  say  those  between  30 
and  40  years,  the  reverse  is  true,  the  patients  frequently  being  individ- 
uals inclined  to  weakness,  and  having  a  general  aspect  that  is  decidedly 
phthisical,  pallor  of  the  face,  etc.  This  is  particularly  true  of  individ- 
uals becoming  afflicted  with  U'mpho-sarcomatous  processes. 

Heredity 

Any  typical  findings  amongst  relations  and  ancestral  lines  are  en- 
tirely out  of  the  question.  Longevity  and  health  of  the  parents  I  con- 
sider the  most  common.  In  group  number  2,  Ave  do  indeed  not  infre- 
quently find  tuberculosis  among  ancestors,  and  individuals  with  healed 
tubercular  foci  are  predisposed  to  cancer  in  a  somewhat  higher  degree. 
Personally,  I  do  not  consider  transmission  in  a  similar  sense,  at  least,  as 
far  as  gastric  cancer  is  concerned,  to  be  of  frequent  occurrence.  Yet, 
many  an  ancestral  tree  that  has  been  studied,  scarcely  leaves  room  for 
doubting  the  possibility  of  direct  transmission.'*'* 

Here  we  may  dismiss  the  notion  that  gastric  cancer,  as  such,  is  trans- 
missible. It  would  seem,  however,  that  functional  debility  of  an  organ 
(weak  stomach,  varicose  veins,  hemorrhoids,  etc.),  are  hereditary  in  some 
families,  and  this  certainly  holds  good  also  of  constitutional  anomalies 
of  dyscrasia,  such  as  gout,  diabetes,  etc. 

It  must  also  be  borne  in  mind  that  certain  neoplasms  are  especially 
frequent,  this  being  true  of  cancer  of  the  stomach;  so  if  the  patient  shows 

*'^  Leser,   Munchener  Med.  Wochenschr.,   1901,   No.   51. 

■"See:  ,/.  Wolff.  Die  Lehre  von  der  Krebskrankheit,  u.s.w.  1907,  page  361. 
Verlag   von   Gustav    Fischer. 


ETIOLOGY    OF    MALIGNANT    TUMORS  51 

a  disposition  to  nialij[>iiant  disease,  the  probable  chance  of  affecting  one 
of  the  more  fretjuent  phices,  e.g.,  the  stomach,  are  in,  and  of  themselves, 
very  great. 

Diatheses 

Diatheses,  as  met  with  in  cases  of  gout,  diabetes,  and  constitutional 
adiposity,  seem  to  be  of  especially  frequent  occurrence  among  the  ances- 
tors and  relatives  of  cancer  patients. 

But,  even  in  cancer  patients  themselves,  it  is  not  altogether  too  rare 
that  we  meet  with  the  anomalies   of  metabolism  just   referred  to.''" 

Uratic  Diathesis 

Personally,  I  hold  that  rheumatic  antecedents  in  all  stages  up  to 
genuine  gout  are  of  very  frequent  occurrence.  It  seems  remarkable  to 
me  that  those  previously  mentioned  small  angiomatous  formations  of  the 
skin  in  my  experience  frequently  coincide  in  large  numbers  with  a  uratic 
diathesis.  It  is  quite  conceivable  that  alterations  in  the  body  fluids 
might  stimulate  growth  of  cells  predisposed  thereto,  or  unfavorably  in- 
fluence causatively  considered  chronic  inflammatory  processes  of  the 
mucous  membranes,  preventing  their  cure. 

It  is  possible  that  a  chemical  irritant,  taken  in  with  drinking-water 
and  exerting  its  influences  by  way  of  the  body  fluids,  might  be  at  the  bot- 
tom of  adenomatous  formations  in  endemic  goitre.  Attention  might  also 
be  called  to  the  relations  of  diabetes  to  xanthomatous  tumor  formations. 

Internal   Traumas 

Long-combined  internal  traumas,  produced  by  an  abnormal  mixture 
of  different  body  fluids,  seem  to  me  exceedingly  worthy  of  attention  as 
predisposing  causes  of  malignant  cell-proliferations. 

The  objection  that  this  would  have  to  lead  to  numerous  multiple 
growths  falls  flat.  As  in  other  instances,  a  dyscrasia  can  confine  itself  to 
one  locality  (e.g.,  isolated  affection  of  the  large  toe- joint  in  gout).  Aside 
from  that,  we  are  here  dealing,  as  already  mentioned,  with  only  an  occa- 
sional cause  which  presupposes  the  existence  of  other  local  causes  in  com- 
bination with  which  alone  it  becomes  effective. 

With  such  extensive  limitations  it  seems  to  me  that  the  dyscrasia  doc- 
trine of  Rokitansky  and  others  was  not  entirely  erroneous.  The  notion 
of  "internal  cell-injuries"  due  to  abnormal  body  fluids  will  be  forced  upon 
us  in  those  cases,  for  instance,  where  in  the  same  individual  there  is  a 
multiple  occurrence  of  benign  and  malignant  tumors  which  are  entii-ely 
independent  of  each  other,  or  where  malignant  proliferative  processes 
occur  in  different  parts  of  the  same  system  (lymphatic  and  myeloid  sys- 
tems, both  ovaries,  both  suprarenal  bodies,  etc.). 

Cirrhosis  of  the  Liver 

Furthermore,  attention  seems  to  be  due  the  relations  between  cir- 
rhotic processes  and  such  as  develop  outside  of  the  liver,  e.g.,  intestinal 

■"See:  Boas,  Uber  Carcinom  und  Diabetes.  Berliner  Klin.  Wochenschr.,  1903, 
page  243. 


52  TUMORS    OF    THE    ABDOMINAL    VISCERA 

carclnomata.  Aside  from  some  dyscrasia  resulting  from  restricted  func- 
tions of  the  liver  we  would  here  also  have  to  consider  local  congestion  as 
a  favoring  factor. 

Climatic  Injuries 

In  numerous  articles  it  is  proven  that  conditions  of  the  soil  may, 
under  circumstances,  cause  the  frequency  of  cancer  cases.  This  is  said 
to  be  true  of  clay  and  mud  soils,  of  the  location  of  dwellings  along  streams 
where  frequent  inundations  take  place,  of  damp  houses,  etc. 

Opposed  to  this  it  seems  that  in  dry,  hot  countries,  malignant  new- 
growths  are  rare — such  is  the  claim  made  for  Tunis  and  Algiers.  The 
first-mentioned  influences  are  decidedly  calculated,  through  their  interfer- 
ence with  the  function  of  the  skin,  to  induce  and  promote  disturbances  in 
the  nature  of  a  dyscrasia  such  as  "rheumatic"  diathesis,  and  it  appears  to 
me  personally  the  kind  of  a  connecting  link  that  is  far  more  probable 
than  the  conclusion  which  is  usually  drawn  from  it  as  to  the  presence  of 
a  specific  cancer  parasite. 

Mind 

If  trouble  and  worry — psychical  factors — are  at  times  jointly  ac- 
cused, it  seems  to  me  deserving  of  note  that  these  are  influences  which 
may  ultimately  lead  to  a  retardation  and. alteration  of  metabolism. 

Thus  our  forefathers  looked  upon  a  phlegmatic  temperament  as  one 
of  the  causes  of  cancer.  Temperament  and  metabolism  may  indeed  bear 
relations  to  each  other  as  far  as  changes  are  concerned. 

Whoever  looks  at  constitutional  and  dyscrasic  factors  as  a  partial 
cause,  at  least  in  some  cases,  will  not  permit  infectious  processes  to  pass 
unheeded,  since  they  are  capable  of  imparting  to  the  body  fluids  a  last- 
ing characteristic  (agglutination  phenomena,  Wassermann  reaction),  and 
may  certainly  lead  to  an  alteration  of  the  entire  organism,  as  is  demon- 
strated in  cases  where  persons  have  only  once  passed  through  a  certain 
infectious  disease,  especially  in  childhood. 

An  analysis  of  my  observations  along  this  line  ^^  has  convinced  me 
that  in  a  conspicuously  large  percentage  of  cases  the  past  history  of  can- 
cer patients  very  rarely  or  never  discloses  any  infectious  diseases,  and 
this  is  true  principally  of  the  infectious  diseases  of  childhood. 

"Never  was  sick"  is  the  surprisingly  frequent  response  often  elicited 
from  cancer  patients  who  are  far  advanced  in  age. 

Should  this  observation  of  mine  be  bonie  out  later  on,  and  I  am  in- 
clined to  think  it  will,  then  I  can  see  only  two  explanations. 

1.  Attacks  of  infectious  diseases,  especially  infectious  diseases  of 
childhood,  afl'ord  a  certain  protection  against  subsequent  disease  from 
malignant  neoplasms.  From  this  there  would  follow  a  mighty  prophylac- 
tic perspective.     Or 

2.  Individuals,  whose  congenital  constitutions  later  on  incline  to  ma- 
lignant neoplasms,  have  a  certain  immunity  particularly  against  infec- 
tious diseases  of  childhood. 

"  Krebs  und  Infektionserkrankungen.     Med.  Kllnik,  1910. 


ETIOLOGY    OF    MALIGNANT    TUMORS  53 

Cancer  and  Tuberculosis 

Since  Rokitansky  promulgated  his  theory  of  antagonism  between  can- 
cer and  tuberculosis,  basing  his  opinions  on  dyscrasias,  numerous  works 
have  been  written  on  this  theme.  I  would  like  to  sum  up  my  own  opinions 
by  saying  that  individuals  with  well-developed  progressing  tuberculosis 
of  the  lungs  are  extremely  unlikely  to  have  carcinoma.  On  the  contrary, 
healed  apical  lesions  and  other  stationary  healed  tubercular  processes, 
or  such  as  incline  to  healing,  especially  those  of  glands  and  bones,  are 
decidedly  not  rare  in  cancerous  patients. 

Lues 

In  regard  to  the  fi-equenc}'  of  lues  in  the  past  history  of  cancer  pa- 
tients there  is  no  agreement.  My  personal  impression  is  that  so  far  as 
the  clinical  study  of  malignant  neoplasms  is  concerned  luetic  antecedents 
are  not  frequent. 

b.    Exogenous  Local  Causes 

Exogenous  Local   Causes 

The  presence  of  concretions  in  the  gall-bladder  figures  among  the 
best  known  local  causes  of  malignant  proliferative  processes. 

Gail-Stones 

All  statistical  observations  agree  in  this  respect  that  in  the  vast  ma- 
jority of  cases  the  development  of  cancer  in  the  gall-bladder  coincides 
with  the  presence  of  concretions.  That  the  latter  are  pre-existent  is  ap- 
parent in  many  cases  from  the  data  of  the  past  history.  Whether  we 
are  here  concerned  with  a  purely  traumatic  irritant  must  remain  an  open 
question.  In  this  connection  there  may  enter  into  consideration  the 
chemical  composition  of  bile  and  preceding  chronic  inflammatory 
processes  of  the  gall-bladder  mucosa. 

Gastric   Ulcer 

With  reference  to  the  much-discussed  relations  between  gastric  ulcer 
and  cancer  of  the  stomach  I  take  the  personal  stand  that  in  only  a  small 
percentage  of  cases  does  cancer  of  the  stomach  become  superimposed  on 
a  gastric  ulcer,  but  not  seldom  during  the  course  and  even  in  the  begin- 
ning of  a  malignant  process  ulcer-like  defects  develop  in  the  mucous  mem- 
brane of  the  stomach,  and  it  seems  that  A'cry  often  these  have  led  to  the 
anatomical  diagnosis  of  "cancer  on  an  ulcerated  base."  ^^ 

In  many  such  cases  which  I  saw  on  the  operating  table  a  most  exact 
anamnesis  had  not  furnished  the  least  ground  on  which  to  assume  a  pre- 
existing ulcer. 

Mechanical  Traumas 

Mechanical  traumas  in  and  of  themselves,  without  simultaneous  chemi- 
cal irritants,  could  hardly  ever  be  a  causative  factor  of  any  importance, 
and  least  of  all  when  there  is  question  of  but  a  single  acute  trauma. 

^''See:  Hauer,  Uber  Magengeschwiire  unci  Carcinom.  Miinchener  med.  Wochen- 
schr.,  1910,  No.  23. 


54-  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Chemical  Irritants 

Long-combined  chemical  irritants  are  undoubtedly  more  significant. 
As  far  as  the  skin  is  concerned  their  causative  effect  displays  itself  in 
manifold  plastic  ways,  the  epitheliomas  observed  in  chimney-sweeps,  tar 
and  paraffin  workers  being  classic  witnesses. 

The  application  of  such  observations  to  the  mucous  membranes  of 
the  alimentary  tract  is  obvious.  There  is  hardly  a  doubt  that  cancer  of 
the  esophagus  occasionally  stands  in  some  relation  with  imbibition  of 
whiskey,  which  explains  its  prevalence  in  male  individuals. 

The  particular  frequency  of  rectal  carcinoma  is  probabl}'  explained 
by  the  especially  favorable  conditions  for  mechanical  and  chemical  in- 
juries. 

Here,  also,  the  previously  mentioned  internal  chemical  irritants, 
such  as  altered  body  fluids,  disturbance  of  nutrition  from  local  arterio- 
sclerosis, venous  congestion,  etc.,  may  act  conjointly  with  other  factors. 

Roentgen  Rays 

Recently,  also,  the  Roentgen  rays  have  come  to  figure  among  those 
injuries  which  under  the  circumstances  may  be  looked  upon  as  predis- 
posing causes  of  skin  cancer. 

Chronic  Inflammation 

Despite  their  individual  differences,  a  common  feature  unites  the 
exogenous  injuries  just  discussed:  with  proportionate  degree  of  severity 
and  proportionate  duration  of  their  action  they  all  end  in  a  chronic  in- 
flammatorij  condition  of  the  affected  tissue. 

It  seems  that,  on  such  a  foundation,  degeneration  into  a  malignant 
tumor-cell  takes  place  most  easily. 

Taken  in  this  sense — as  excitants  of  inflammation — it  may  be  that 
now  and  then  this  or  that  microbe  enters  into  only  a  subordinate  causal 
relation  to  tumor  formation,  which  is  exemplified  when  under  certain  cir- 
cumstances tubercular  or  luetic  tissue  processes  seem  to  afford  favorable 
preliminary  conditions  for  malignant  cell-proliferation. 

None  of  the  influences  formerly  discussed,  whether  of  an  endogenous 
or  exogenous  nature,  are  entitled  to  be  classed  as  a  specific  cause.  Pos- 
sibly there  is  no  such  cause  for  malignant  neoplasms.  Many  components, 
changing  from  case  to  case  with  regard  to  origin  and  severity,  unite  in 
producing  the  resulting  malignant  cell-proliferation. 

Each  single  case  has  its  particular  place  with  reference  to  causative 
influences,  and  requires  separate  analysis. 


ETIOLOGICAL    NOTEWORTHY    FACTORS  55 


ETIOLOGICAL    NOTEWORTHY    FACTORS    IN    THE    TAKING 
OF   HISTORIES   OF   MALIGNANT    NEOPLASMS 

Since  all  probabilities  indicate  that  a  specific  and  uniform  cause  for 
malignant  neoplasms  does  not  properly  exist,  but  that  from  case  to  case 
there  is  an  underlying  combination  of  endogenous  and  exogenous  bio- 
logical irritants  and  dispositions,  in  connection  with  the  previously  de- 
tailed discussions  as  to  the  etiology  of  malignant  neoplasms,  I  would  like 
to  sum  up  in  a  superficial  manner  the  points  which  seem  important  to  me 
in  the  recording  of  case  histories. 

While  fully  appreciating  local  exogenous  causes  of  disease,  I  wish  to 
lay  especial  stress  upon  congenital  peculiarities  and  the  possibility  of 
congenital  transmission.  Information  from  the  patient  as  to  the  follow- 
ing points  will  be  of  service. 

1.  Maternal,  at  times  paternal,  organism?  Longevity  of  parents? 
Dyscrasias  in  parents,  such  as  gout,  adiposity,  diabetes?  Malignant 
neoplasms  or  tuberculosis?  In  the  same  manner  ascertain  the  same  facts 
concerning  patient's  own  brothers  and  sisters,  the  maternal  grandmother 
and  her  descendants. 

2.  Constitution  of  patient  during  childhood.  Weak?  Strong? 
Scrofulous  and  rachitic? 

3.  What  infectious  diseases  of  childhood  have  been  passed  through? 
What  infectious  processes  later  on?  Tuberculosis?  Lues?  ]\Ialaria? 
Typhoid?     Pneumonia? 

4.  Is  the  individual  one  who  has  always  enjoyed  robust  health? 

5.  Is  there  anything  in  the  patient  which  might  give  the  impression 
of  constitutional  inferiority? 

a.  What  place  does  the  patient  occupy  in  line  of  seniority 
with  reference  to  other  children?  How  old  was  the  mother 
at  time  of  patient's  birth? 

h.  Enteroptosis? 

c.  Epilepsy?     Migraine? 

6.  Constitutional  characteristics  at  and  before  beginning  of  disease: 

a.  General  appearance?  Temperament?  Color  of  hair?  Fall- 
ing out  of  hair?     Gray  early?     Arcus  senilis  of  the  cornea? 

h.  Circulatory  anomalies:  Tendency  to  varicose  veins  and 
hemorrhoids  (hereditary  conditions?)  congenital  inclination 
to  epistaxis?  Arteriosclerosis?  Blood-vessel  tumors  in  the 
skin  (angioma)  ? 

c.  Skin:    Psoriasis  vulgaris?     Chronic  eczema?     Ichthyosis? 

d.  Does  anything  in  the  patient  suggest  a  gouty  diathesis  or 
other  allied  conditions?  {Heherden's  nodes?  Hallux  val- 
gus as  analogous  to  similar  deviation  in  metacarpo- 
phalangeal articulations?  Sciatica,  Lumbago?)  Diabetes, 
adiposity,  thyroid-gland  anomalies? 


56  TUMORS    OF    THE    ABDOMINAL    VISCERA 

7.  Is  there  a  general  tendency  to  the  occurrence  of  new  formations, 
e.g.,  angiomas  of  the  skin  or  cysts,  myomas,  etc.,  about  the  female 
genitals .'' 

8.  Have  chronic  injuries  of  mechanical  or  chemical  nature  been  at 
work  in  the  site  of  the  disease .''  (Concretions,  pressure  upon  the  epigas- 
trium by  leaning  up  against  tools,  etc.,  abnormalities  of  diet?) 

9.  Was  the  affected  organ  anatomically  and  functionally  up  to  or  be- 
low par  prior  to  the  disease.'^  (Gastric  ulcer.''  Gastric  neuroses .-^  Achy- 
lia  gastrica.'^     Hemorrhoidal   conditions.''      Cirrhosis .^      Cholelithiasis.'') 


In  conclusion,  brief  mention  may  be  made  of  those  points  which  on 
the  strength  of  personal  impressions  I  consider  worthy  of  note.  Where 
we  are  concerned  with  such  an  extremely  difficult  question  as  is  embodied 
in  the  disposition  to  cancer,  the  individual  observer  can  never  arrive  at  a 
definite  conclusion  but  can  only  gain  impressions  which,  be  they  ever  so 
convincing  to  the  observer  himself,  cannot  be  proved  objectively.  Yet, 
their  probability  may  be  gradually  augmented  through  similar  experi- 
ences of  others,  and  finally  amount  to  certainty.  Thus  impressions  which 
originally  partook  more  of  an  ingenious  significance  may  come  nearer 
being  observed  facts  fully  qualified  for  natural  science. 

With  reference  to  cancer  of  the  stomach,  this  being  by  far  the  most 
frequent  of  internal  cancers,  my  fairly  abundant  experience  in  this  do- 
main and  observation  centred  thereon  have  given  me  the  following  im- 
pressions : 

1.  The  majority  of  patients  are  robust  individuals,  very  often  de- 
scended from  long-lived  parents,  and  in  fact  coming  from  a  very  healthy 
family,  the  patients  often  declaring  that  they  have  been  healthy  all  their 
life.  Frequently  one  would  be  tempted  to  speak  of  "excessive  well-being" 
and  to  assume  that  also  in  this  direction  a  certain  normal  state  cannot 
be  overstepped  with  impunity.  Very  often  infectious  diseases  of  child- 
hood are  denied,  and  also  the  number  of  subsequent  infectious  diseases, 
in  so  far  as  they  affect  the  entire  organism,  is  very  slight  in  this  group 
of  cases.  Opposed  to  this  there  are  often  at  hand  the  marks  of  a  uratic 
diathesis,  and  accordingly  the  history  often  discloses  arthritic  and  neural- 
gic disease  processes.  Neither  is  it  rare  that  these  latter  shortly  precede 
the  beginning  of  the  malignant  disease.  There  are  also  cases  in  wliich  espe- 
cially the  skin  of  the  family  stock  appears  as  if  sprinkled  with  dotlike 
angiomas. 

With  this  type  arteriosclerosis  is  a  frequent  finding.  The}^  are  usually 
individuals  who  enjoyed  very  good  digestive  powers. 

The  anamnesis  not  seldom  elicits  the  fact  that  the  hair  has  turned 
gray  prematurely.  The  eyebrows  are  often  conspicuous  because  of  their 
enormous  development. 

2.  In  partial  contradistinction  to  the  type  of  cases  just  described, 
which  occur  mostly  in  the  later  years  of  life  ("dynamic  type"),  there  is 
another  category  of  patients  who  often  are  attacked  by  gastric  cancer 


PROPHYLAXIS    OF    MALIGNANT    TUMORS  57 

while  still  in  the  thirties  and  forties  ("adynamic  type").  Their  consti- 
tution very  frequently  exhibits  marks  of  congenital  inferiority,  as  shown 
by  features  that  arc  "phthisical"  and  enteroptotic.  Not  rarely  in  these 
cases  does  the  tuberculin  test  point  to  latent  tubercular  foci  (mediastinal 
glands,  etc.),  or  there  exist  manifest  signs  of  arrested  tubercular  foci 
(glands,  bones,  pulmonary  apices,  etc.).  Arteriosclerosis  is  mostly  absent, 
the  blood-vessels  have  a  delicate  feel,  anamnesis  not  seldom  draws  out  the 
fact  of  a  tendency  to  epistaxis  from  early  childhood.  Very  often  they 
are  individuals  who  have  suffered  their  life  long  from  a  "weak  stomach," 
whose  nervous  "irritable  weakness"  also  exhibited  itself  in  their  digestive 
energy. 

To  this  "adynamic"  group  also  belong  most  cases  of  pre-existing  gas- 
tric ulcer.  Achylia  gastrica  might  also  be  said  to  be  pre-existent  in  these 
cases.  Among  their  ancestors  we  not  seldom  meet  with  tuberculosis.  The 
eyebrows  frequently  are  only  indicated. 

PROPHYLAXIS    OF    MALIGNANT    TUMORS 

Clinical  observations  would  seem  to  justify  one  speaking  of  cancer 
prophylaxis,  and  the  thought  that  there  is  a  hygiene  which  protects  to 
a  certain  extent  against  taking  disease  from  malignant  tumors,  deserves 
to  be  carried  from  the  physician's  office  to  the  laity. 

The  prophylactic  measures  naturally  proceed  from  our  notions  as  to 
the  causes  of  the  different  malignant  diseases  of  organs,  and  as  has  been 
made  clear  in  our  former  discussions,^^  in  addition  to  positive  exogenous 
injuries  there  will  also  come  into  consideration  those  rather  hypothetical 
endogenous  irritants. 

Many  of  these  irritants  are  undeniable  as  predisposing  causes,  many 
are  based  on  personal  opinion,  hence  prophylactic  advice  will  partly 
bear  a  personal  stamp. 

Are  those  immediately  surrounding  a  cancer  patient  to  protect  them- 
selves in  any  way  against  contact  with  the  patient  or  his  personal  uten- 
sils.'^    Does  there  exist  the  danger  of  infection.'^ 

Danger  of  Infection 

Following  observations  on  animals  (transmission  of  canine  vaginal 
sarcoma  to  the  dog's  penis  after  coitus),^*  and  similar  confirmed  observa- 
tions of  very  experienced  clinicians  (cancer  a  deux),  this  question  will 
have  to  be  answered  in  the  affirmative. 

Even  though  one  be  an  absolute  opponent  of  the  theory  of  a  specific 
cancer  e!xcitant,  one  can  find  an  explanation  in  the  assumption  that  under 
circumstances  tumor  cells  can,  through  their  extensive  emancipation  from 
the  parent  organism  and  their  great  biologic  independence — analogous 
to  unicellular  microbes — in  case  they  become  liberated  through  ulceration 
and  immediately  gain  access   alive  to   other  organism,  take  root   and — 

"  See  page  49. 

"Zeitschr.   f.  Krebsforschung.  VIII,  3,  4.,  page  5Q5. 


58  TUMORS    OF    THE    ABDOMINAL    VISCERA 

comparable  to  inoculation  experiments  in  mice — continue  to  proliferate 
in  a  characteristic  manner. 

Thiersch  has  found  that  during  the  process  of  transplantation  even 
normal  epithelial  cells  may  take  root  in  a  different  organism. 

It  will,  therefore,  surely  be  advisable  not  to  use  an  uncleaned  spoon  of 
a  patient  having  cancer  of  the  stomach,  to  avoid  kissing  him,  etc. 

Among  internal  carcinomas,  those  that  are  ulcerating  near  the  oral 
and  anal  openings  will  demand  special  precautions. 

Everything,  however,  indicates  that  the  danger  of  direct  transmission, 
especially  as  far  as  carcinoma  of  the  digestive  tract  is  concerned,  is 
almost  insignificant,  and  could  be  compared  to  the  probability  there 
would  be  of  a  railroad  collision  when  one  makes  but  a  single  short  trip. 


Another  practically  important  question  would  be:  Is  there  a  prophy- 
laxis— naturally  a  relative  one  only — for  those  individuals  who  have  been 
successfully  operated  on  for  gastro-intestinal  cancer  or  individuals  who, 
because  of  the  frequent  occurrence  of  cancer  among  their  ancestry,  fear 
analogous  disease.'' 

This  question  also  must  be  unconditionally  answered  in  the  affirma- 
tive. Putting  it  briefly,  the  prophylaxis  seems  to  me  to  consist  of  a  local 
and  general  hygiene. 

I.  Local  Hygiene 

Local  Hygiene 

Since  irritants  which  lead  to  a  chronic  inflammation  undoubtedly  enter 
into  consideration  as  predisposing  causes  in  many  cases  of  malignant 
disease  of  internal  organs,  the  prophylaxis  will  have  to  be  rather 
strenuous. 

Individuals  who  have  had  gastric  ulcer  or  those  who  have  been  surgi- 
cally freed  from  cancer  of  the  stomach,  will  have  to  subject  themselves 
to  a  diet  devoid  of  mechanical,  thermic  or  chemical  irritants  that  are 
liable  to  produce  trauma.  From  this  point  of  view  it  will  be  advisable  to 
exercise  painstaking  care  of  the  mouth  and  teeth. 

Whiskey  drinkers  ought  to  be  cautioned  of  the  danger  of  esophageal 
cancer,  and  even  in  the  case  of  other  patients,  providing  they  are  not 
of  too  apprehensive  a  nature,  it  may  not  be  amiss  to  point  out  the  greater 
likelihood  of  cancer  if  the  hygienic  advice  is  not  observed. 

The  more  the  natural  lessons  of  hygiene  become  impressed  on  the 
popular  mind,  especially  with  reference  to  diet,  the  fewer  will  be  the  cases 
of  gastric  cancer  and  vice  versa. 

If,  as  is  borne  out  by  my  personal  observation,  previously  robust 
constitutions  arc  afflicted  with  gastric  cancer,  I  can  see  one  of  the  causes 
for  it  in  the  scorning  manner  in  which  these  "stomach  athletes"  break 
the  rules  of  gastric  hygiene. 

Nutritional  excesses  may  in  one  or  the  other  case  undoubtedly  become 
predisposing  causes. 


PROPHYLAXIS    OF    MALIGNANT    TUMORS  59 


II.  General  Hygiene 

General  Hijgiene 

Whoever  shares  my  personal  view  of  "internal  cell  traumas"  brought 
about  by  conditions  of  dyscrasia  such  as  uratic  diatheses  and  other  meta- 
bolic disturbances,  and  in  fact  whoever  is  of  the  opinion  that  the  general 
constitutional  level  of  the  organism  is  not  without  influence  from  case 
to  case  as  a  predisposing  cause,  will  have  due  regard  for  these  factors 
after  operative  removal  of  malignant  tumors  as  well  as  in  cases  hered- 
itarily disposed  toward  malignancy. 

It  does  not  seem  too  remote  a  thought  to  occasionally  place  such 
individuals  under  different  climatic  conditions  (hot  and  dry)  in  which 
malignant  neoplasms  appear  to  be  rare  (Tunis,  Algiers).  On  the  other 
hand,  to  take  them  out  of  places  which,  perhaps,  through  favoring  the 
disease  by  promoting  dyscrasias  have  often  been  accused  etiologically 
(damp  dwellings  along  streams,  damp  clay  and  mud  soils). 

Change  of  quality  and  excitation  of  metabolism  by  means  of  nuld 
diaphoresis,  mild  drink  cures,  etc.,  will  suggest  themselves  in  addition  to 
appropriate  dietetic  measures. 

Harmful  psychical  factors  also  (carcinomaphobia)  will  have  to  be 
eliminated  as  far  as  possible. 


B.  SPECIAL  PART 


Cancer  of  the  Stomach^ 

EARLY  SYMPTOMS 

One  is  so  accustomed  to  see  malignant  new-growths  of  internal  organs 
at  so  late  a  stage  of  their  development,  that  the  notion  of  a  gastric 
cancer  being  the  size  of  a  millet  seed  sounds  rather  strange  to  the  diag- 
nostician. 

And  yet  every  tumor  which  later  on  impresses  us  so  forcibly  on 
account  of  its  dimensions  must  develop  from  the  minutest  size. 

We  are  probably  justified  in  assuming  that  these  initial  stages  will 
forever  remain  inaccessible  territory  to  clinical  diagnosis. 

For  even  if  we  grant  the  possibility  that  the  development  of  cancer 
cells  can  change  the  bulk  of  the  body  fluids  in  any  specific  way,  and  this 
specific  change  could  be  demonstrated,  it  would  still  be  more  than  doubt- 
ful that  such  a  specific  dyscrasia  should  accompany  the  very  first  develop- 
ment of  cancer. 

At  what  time,  then,  does  carcinoma  of  the  stomach  enter  the  field  of 
internal  diagnosis,  since  its  first  initial  stages  interest  only  biologists 
and  histologists.'* 

This  question  permits  of  the  following  answers: 

1.  When  it  ulcerates  and  leads  to  the  presence  of  blood-coloring  mat- 
ter in  the  stomach  contents  and  feces. 

2.  When  it  begins  to  disturb  the  function  of  the  affected  organ. 

Blood  in  the  Feces 

If,  for  example,  we  allow  two  years  for  the  average  duration  of  cancer 
from  its  very  beginning,  the  question  arises:  When  (on  the  average) 
does  the  cancer  begin  to  ulcerate.'' 

If  we  remember  that  the  mucous  membranes  of  the  stomach  and  duo- 
denum are  particularly  inclined  to  ulcerative  processes  and  which  ex- 
plains the  foregoing,  unlike  almost  any  other  area  of  mucosa  is  con- 
stantly subjected  to  chemical,  thermal  and  mechanical  irritants,  the 
assumption  surely  lies  near  at  hand  that  in  case  of  malignant  disease 
ulceration  will  set  in  early. 

For  the  much-desired  early  diagnosis  of  gastro-intestinal  cancer  the 
following  urgent  postulate  will  apply:  In  cases  of  gastro-intestinal  dis- 

^  The  numbers  in  the  text  and  in  the  foot-notes  refer  to  the  respective  case  his- 
tories.— Here  I  have  in  mind  those  quantitatively  small  hemorrhages  which  cannot  at 
all  be  made  out  macroscopically  nor  demonstrated  with  desirable  certainty  under  the 
microscope,   but  whose   presence  can   be  proved   by   the  chemical   test. 

63 


64  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ease  repeated  clieniical  examinations  of  the  feces  for  blood-coloring  mate- 
rial are  absolutely  necessary. 

In  such  cases  one  might  think  of  demonstrating  a  gastric  hemorrhage 
by  washing  out  the  stomach.  Still,  it  must  be  remembered  that  exam- 
ination of  the  feces  yields  an  approximately  twenty-four  hour  result, 
whereas  lavage  of  the  stomach — barring  the  presence  of  stagnation — 
will  only  determine  whether  a  hemorrhage  has  occurred  at  or  shortly 
before  the  time  of  lavage;  at  the  same  time  we  will  also  have  to  reckon 
with  the  possibility  of  artificially  produced  hemorrhage  brought  about 
by  the  introduction  of  the  stomach-tube,  straining,  etc. 

For  this  and  other  reasons  the  Salomon  test"  seems  but  little  com- 
mendable. It  proceeds  from  the  supposition  that  bloody  serous  fluid 
containing  albumin  transudes  from  the  ulcerating  surface,  and  aims  at 
demonstrating  albumin  according  to  Esbach  or  through  N-determination 
in  the  reflow  (Kjehlahl).  It  is  said  that  if  there  be  over  20  mg  N  in 
100  cm.*^  reflow  (400  cm.^  being  the  total),  it  involves  suspicion.  The 
same  is  said  of  -Ke— "1/2%  Esbach. 

It  is  certain  that  a  positive  outcome  may  result  even  without  cancer 
of  the  stomach,  there  being  various  possibilities,  such  as  peptic  ulcer, 
chronic  gastritis,  swallowed  sputum,  etc.  A  negative  result  may  occur 
even  in  advanced  carcinoma. 

In  view  of  the  small  results  obtained  this  test  is  not  likely  to  become 
clinically  prevalent,  because  it  requires  a  second  introduction  of  the 
stomach-tube ;  the  food  remnants  are  washed  out  in  the  evening  and  the 
following  morning  400  cm^  of  water  are  introduced  and  withdrawn 
twice,  thus  subjecting  the  patient  to  three  washings,  including  that  after 
the  test-breakfast. 

In  advanced  gastric  cancer  accompanied  by  stagnation,  the  test  will 
certainly  often  turn  out  positive,  but  in  such  cases  it  will  give  way  to 
methods  of  examination  that  are  simpler  and  admit  of  fewer  interpre- 
tations. 

Disturbances  of  Motility  and 
Its  Consequences 

For  diagnostically  obscure  cases  I  consider  the  above  test  as  too 
uncertain  in  its  results — both  negative  and  positive — to  be  of  any  real 
value  in  aiding  and  determining  diagnosis. 

Thus  it  happens  that  of  the  various  functions  of  the  stomach,  and 
incidentally  those  of  the  bowel,  the  motor  function  is  in  many  cases  the 
first  to  suffer. 

If  the  cancer  be  situated  in  the  pyloric  or  prepyloric  portion  of  the 
stomach,  then,  in  addition  to  the  impeded  onward  movement  of  gastric 
contents  on  account  of  direct  encroachment  of  the  tumor-mass  in  the 
lumen,  there  also  come  into  consideration  swellings  of  the  mucosa  and 

^  H.  Salomon,  Deutsche  med.  Wochenschr.,  1903,  No.  31. — The  frequent  localization 
of  gastric  cancer  at  the  pylorus  or  in  its  immediate  vicinity  (curv.  minor.,  prepyloric) 
makes  it  apparent  that  stagnation  of  the  stomach  contents  not  seldom  belongs  to  the 
early  symptoms. 


CANCER    OF    THE    STOMACH  65 

pyloric  spasms ;  but  even  if  otherwise  situated  the  tough  infiltration  of 
even  only  a  circumscribed  area  cannot  be  without  effect  on  peristalsis. 

Also,  ptosis  of  a  carcinomatous  stomach,  due  to  the  disappearance 
of  intra-abdominal  adipose  tissue,  may  favor  stagnation,  and  thus  aug- 
ment the  resultant  subjective  sensations  such  as  pressure  in  the  stomach. 
Adjustment  of  the  ptosis  through  pressure  from  below  upward  will  then 
afford  relief. 

In  the  same  measure  that  the  expulsion  of  the  ingested  food  becomes 
gradually  more  and  more  retarded,  and  the  foods  that  do  not  gain 
access  to  the  bowel  in  time  are  subjected  to  bacterial  decomposition, 
there  results  a  set  of  symptoms  which  must  often  be  construed  as  direct 
evidence  of  increasing  stagnation.  These  symptoms  may  now  be  discussed 
in  the  order  in  which  they  frequently  follow  each  other  as  early  symptoms. 

a.  Pressure  in  the  Stomach 

The  more  or  less  painful  sensation  of  fulness  in  the  epigastrium  after 
eating  is  in  many  cases  the  first  signal  for  alarm. 

The  pathogenesis  of  the  symptom  is  made  clear  by  the  fact  that  the 
evacuation  of  the  gaseous  and  thickly  fluid  stomach  contents  through 
belching  or  vomiting  affords  immediate  relief.  Not  infrequently  does  it 
happen  that  at  the  time  of  this  pressure  in  the  stomach  the  epigastrium, 
through  spontaneous  inflation,  bulges  somewhat  and  becomes  tense  like 
an  air-cushion. 

The  interference  with  the  emptying  of  the  stomach  leads  partly 
through  fermentations,  to  abnormally  high  burdening  of  the  stomach- 
walls,  and  it  is  this  increased  internal  pressure  in  the  first  place  that 
causes  the  symptom. 

Not  infrequently  it  precedes  the  objectively  demonstrable  stagnation 
b}^  a  considerable  period  of  time,  and  therefore  merits  serious  consid- 
eration. 

Topography 

Wliilst  the  sensation  of  pressure  in  the  stomach  is  most  often  dif- 
fusely localized  in  the  epigastrium,  there  are  cases  in  which  it  is  felt 
in  the  region  of  the  pylorus,^  or  behind  the  xiphoid  process,  or  in  the 
back.^  N'ot  seldom  stabbing  sensations  are  experienced  on  both  sides 
under  the  costal  margins. 

Time   and  Appearance 

With  reference  to  the  time  of  its  appearance,  this  symptom  is  mostly 
intermittent ;  it  is  related  to  the  time  of  eating,  sometimes  appearing 
immediately,  but  most  often  in  the  following  two  hours,  and  lasting 
about  one  hour;  yet  there  are  cases  in  which  it  exists  more  or  less  con- 
tinuousl3\' 

^No.  33.  *No.  69.  »  Nos.  35,  41. 


66  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Causation 

Its  causation  is  dependent  upon  the  quantity  and  qualit}''  of  the 
food,  and  in  the  individual  case  after  the  fashion  of  a  well-prepared 
experiment,  is  strictly  adherent  to  rule  and  may  be  proved  to  be  so. 
This  point  deserves  attention  in  contradistinction  to  similar  but  more 
capricious  sensations  in  gastric  neuroses.  Though  according  to  rule  and 
unchanging  in  one  and  the  same  case,  the  conditions  for  its  occurrence 
in  different  observations  are  not  entirely  identical.  Although  always  of 
an  alimentary  nature,  there  will  be  differences  with  respect  to  quality  of 
the  badly  agreeing  foods. 

The  severest  sensation  of  pressure  is  produced  chiefly  by  the  intake 
of  solid  foods,  especially  meat.  Cooked  beef,  above  all,  is  tolerated  worst. 
Yet  here,  as  in  all  dietary  questions,  individual  peculiarities  will  play  a 
part.  Thus  it  happens  occasionally  that  certain  kinds  of  meat  which  are 
hard  to  digest,*'  such  as  pork,  are  well  tolerated,  whereas  farinaceous 
foods  give  rise  to  severe  sensation  of  pressure;  in  other  cases  sweets' 
and  vegetables  ^  are  badly  borne. 


Diagnostic  Import 

Can  the  symptom  of  pressure  in  the  stomach,  which  we  are  able  to 
elicit  by  alimentation,  be  utilized  for  the  diagnosis  of  an  incipient  gas- 
tric cancer.'* 

We  find  it  frequently  in  those  digestive  neurasthenics  whose  gastro- 
intestinal canal  labors  under  "irritable  weakness,"  and  is  not  seldom  met 
with  at  the  time  of  the  menopause ;  it  often  precedes  gall-stone  colic  by 
months  and  years ;  it  accompanies  benign  ulcerations  of  the  stomach  and 
cardiac  congestions.  Acute  dyspepsia  after  indigestion,  every  increase 
in  the  volume  of  neighboring  organs  of  the  stomach  which  narrows  space 
(tumors  of  the  liver  and  spleen,  echinococcus  and  pancreatic  cysts,  etc.), 
may  manifest  themselves  subjectively  by  the  sensation  of  pressure  in 
the  stomach. 

The  symptom  may  therefore  result  from  quite  heterogeneous  organic 
conditions.  Nevertheless,  it  deserves  full  consideration  as  an  aid  in 
diagnosis. 

Most  of  the  enumerated  organic  processes  are  easily  excluded ;  prac- 
tically we  are  concerned  only  with  gastric  ulcer  and  neurotic  disturbances 
of  gastric  function. 

If  the  symptom  rests  on  the  following  premises  it  will  lead  us  to 
suspect  cancer  of  the  stomach : 

1.  Unaccountable  and  pronounced  occurrence  in  individuals  who  have 
always  had  strong  stomachs  ("stomach  athletes")  and  have  arrived  at 
the  age  of  cancer. 

2.  Regularity  of  its  occurrence  after  a  certain  quantity  or  quality  of 
food  with  repeated  experimental  control  (in  contradistinction  to  gastric 
neurosis  !). 

«Nos.  18,  66.  'No.  81.  »  No.  59. 


CANCER    OF    THE    STOMACH  67 

3.  Striking  persistence  of  the  symptom  and  but  slight  therapeutic 
results,  when  apparently  it  can  be  accounted  for  by  a  single  dietetic  error. 

•i.  Unchecked  progress  in  the  intensity  of  the  symptom :  The  sensa- 
tion of  pressure  coming  on  in  the  beginning  after  abundant,  later  after 
slight  ingestion  of  food ;  in  the  beginning  intermittent,  later  continuous ; 
in  the  beginning  mild,  later  very  painful. 

The  first  point  which  takes  into  account  the  individuality  of  the  pa- 
tient seems  to  me  especially  important. 

A  "stomach  athlete"  who  suffers  from  gastric  disease  must  be  ap- 
praised differently  than  a  "stomach  weakling." 

Only  a  powerful  etiological  factor  can  disturb  the  functional  equi- 
librium in  the  former  case.  Even  when  the  trouble  is  laid  to  an  error  in 
diet,  the  greatest  scepticism  is  in  order,  particularly  so  if  a  return  to  the 
normal  condition  is  not  soon  established.  Behind  the  "spoiled  stomach" 
and  the  "acute  gastric  catarrh"  of  the  "stomach  athletes"  there  lurks  but 
too  often  a  cancer."  Other  tilings  being  equal,  "stomach  athletes"  are 
more  open  to  the  suspicion  of  cancer  than  "stomach  weaklings,"  as  they 
are  found  among  cancer  patients  in  far  greater  numbers. 

b.    Phenomena  of  Regurgitation 

From  the  same  source  as  the  above  subjective  symptom,  namely,  from 
stagnation  of  the  contents  of  the  stomach,  there  arise  the  symptoms 
which  will  be  discussed  presently,  and  which  from  a  common  point  of  view 
I  would  like  to  designate  as  "phenomena  of  regurgitation." 

They  var}^  all  the  way  from  occasional  eructation  of  gas  to  continued 
copious  vomiting. 

Their  appearance  is  partly  spontaneous,  and  partly  brought  about  by 
stooping,  which  leads  to  a  compression  of  the  abdominal  contents. 

Eructation  of  Gas 

This  phenomenon  may  be  easily  misleading  when  it  is  very  noisj'  and 
explosive-like.  One  is  accustomed,  and  justly  so,  to  make  this  observation 
in  the  cases  of  gastric  neurotics  (aerophagia).  But  it  does  occur  also — 
rarely  indeed — in  cases  of  cancer  of  the  stomach.*' 

"Like  the  whistling  of  a  locomotive"  is  the  comparison  a  patient 
makes  in  one  of  the  case  histories  (36). 

In  the  beginning  the  regurgitating  gases  are  mostly  odorless,  but 
with  further  progress  they  can  be  recognized  as  SH2  by  their  odor  of 
rotten  eggs.^'^  The  presence  of  this  odor  is  usually  concomitant  with 
the  microscopic  finding  of  sarcina  ventriculi.  The  stomach  sarcina  may 
be  considered  the  most  frequent  excitant  of  SH2  fermentation  in  the 
stomach  contents. 

Therefore  in  the  valuation  of  this  symptom  a  higher  appraisal  will 
be  demanded  if  it  occurs  in  individuals  who  formerly  had  strong  stomachs. 

In  contradistinction  to  the  eructation  of  neuropathic  individuals  two 
points  seem  to  me  deserving  of  note: 

»Nos.  2,  36.  "Nos.  23,  36,  45,  49,  51,  56,   61. 


68  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Neurotics  almost  never  complain  of  bad-smelling  eructations. 
Eructations  of  gas,  as  a  result  of  an  organic  gastric  lesion,  frequently 
attract  attention  by  nocturnal  disturbance. 

"Sour"  Eructations   ("Heartburn") 

Belonging  to  the  early  period  of  gastric  cancer,  and  frequently  con- 
comitant with  a  good  appetite,  this  symptom  also  owes  its  existence  to 
motor  insufficiency  of  the  stomach.  Favored  by  stagnation  and  often  also 
by  hypochlorhydria,  there  occur  processes  of  decomposition  which  lead 
to  the  formation  of  organic  acids,  such  as  lactic,  butyric  and  acetic  acids. 
It  is  to  these  acids  that  the  existence  of  the  symptom  can  be  ascribed  in 
cancer  of  the  stomach. 

Nothing  could  be  more  erroneous  than  to  infer  a  hyperchlorhj'dria. 
The  sensation  of  heartburn  here  discussed  extends  upward  along  the 
esophagus  and  occasionally  also  leads  to  sensations  in  the  throat,  which 
must  not  be  interpreted  as  "globus  hystericus"  and  eventually  "gastric 
neurosis." 

The  appearance  of  the  symptom  is  not  seldom  synchronous  with  the 
expulsion  period,  and  therefore  frequently  occurs  two  to  three  hours 
after  the  noonday  meal,  and  occasionally  also  sets  in  at  night. 

The  use  of  bread  sometimes  seems  to  cause  it  promptly. 

Watery  Eructation 

Instead  of  sour  eructation,  or  alternating  with  it,  we  sometimes  meet 
with  regurgitation  of  mouthfuls  of  watery,  tasteless,  or  slightly  salty 
tasting  masses  ^'  (HCl  free  gastric  juice.''),  or  a  slimy  glaring  fluid. ^- 

It  will  be  necessary  not  to  confuse  this  with  the  flow  of  saliva,  which 
can  occasionally  be  observed  as  a  reflex  symptom  in  gastric  cancer  (1-i). 

Vomiting 

Vomiting  stands  at  the  head  of  the  phenomena  of  regurgitation. 
Hence  its  frequent  occurrence  is  often  first  found  in  advanced  stages  of 
the  disease,  but  may  also  be  permanently  absent. 

In  cases  of  diffuse  scirrhus  cancer  of  the  stomach,^ ^  with  extreme 
narrowing  of  its  lumen,  there  is  mostly  frequent  and  copious  vomiting, 
often  even  after  the  use  of  small  quantities  of  fluids. 

Fibrous  cancers,  limited  to  the  pylorus  and  resulting  in  much  stenosis 
with  secondary  gastrectasia,  lead  to  less  frequent  but  therefore  more 
copious  vomiting. 

Non-stenosing  medullary  cancers,  which  often  are  of  enormous  extent, 
not  seldom  run  along  without  vomiting,  so  that  one  must  not  be  misled 
in  diagnosis  by  the  apparent  contrast  of  a  large  tumor  and  no  vomiting. 

With  reference  to  the  time  of  day,  the  vomiting  not  seldom  occurs 
about  the  time  of  the  expulsion  of  the  food  (about  two  hours  after  eat- 
ing), but  frequently  also  prefers  the  midnight  hours. 

Its  first  appearance  is  often  attributed  by  the  patient  to  some 
dietetic  error.^^     In  the  case  of  individuals  with  strong  stomachs,  who 

"  Nos.  69,  74,  99.  "  No.  40.  "  Nos.  2,  25,  "  No.  5. 


CANCER    OF    THE    STOMACH  69 

have  never  vomited  before,  such  attempts  at  explanation  should  always 
be  considered  with  doubt.  Only  too  often  the  dietetic  error  is  merely  the 
exciting  cause,  the  fundamental  cause  being  a  developing  cancer. 

It  seems  that  sometimes  the  use  of  Karlsbad  water  ^^  or  the  use  of 
cold  drinks^^  provokes  the  vomiting.  Liquid  foods  often  act  more  unfa- 
vorably than  solid  ones  (76). 

A  fact  frequently  observed  is  that  the  vomiting  and  the  accompany- 
ing nausea  as  well  as  the  milder  symptoms  of  regurgitation,  such  as 
eructation  of  gas  and  heartburn,  occur  and  are  made  worse  when  lying 
on  the  right  side,^" 

These  throughout  are  cases  in  which  the  cancer  affects  the  pyloric 
portion  of  the  stomach  where  it  has  led  to  a  more  or  less  severe  stenosis 
of  the  outlet. 

The  right-sided  vomiting  attitude  indicates — generally  speaking — a 
local  process  at  the  pylorus  and  is  mostly  a  sign  of  organic  disease. 

The  vomitus  is  mostly  of  an  alimentary  character,  and  frequently 
brings  to  liglit  old  remains  of  food. 

Vomiting  of  bile  is  rare  with  pyloric  stenosis,  and  more  frequent  with 
cancer  of  the  fundus ;  yet,  development  of  cancer  at  the  pylorus  may  lead 
to  insufficiency  of  the  outlet,  in  which  case  there  is  nothing  to  prevent  a 
backward  flow  of  bile. 

Seldom  does  gastric  cancer  make  its  first  appearance  with  vomiting 
of  blood  or  melena  (19,  67),  and  even  in  later  stages  copious  bleedings 
are  rare. 

The  well-known  coffee-ground  vomiting  deserves  full  attention  when 
accompanied  by  abundant  vegetation  of  lactic-acid  bacilli. 

Otherwise  it  is  found  also  with  icterus  gravis,  acute  peritonitis,  gas- 
tric crisis,  agonal  vomiting  in  sepsis,  pneumonia,  etc. 

Feculent  and  fetid  vomiting  may  be  due  to  putrid  ulcerations  (90, 
94),  gastro-colonic  fistula  (18),  or  complicating  ileus. 

c.    Phenomena  of  Pain 

The  development  of  gastric  cancer  is,  in  its  clinical  appearance,  very 
frequently  ushered  in  by  pains. 

To  a  large  extent  they  emanate  from  the  same  source  as  the  symp- 
toms hitherto  discussed,  namely,  from  impeded  evacuation  of  the  stomach 
contents,  in  connection  with  which  there  may  occur,  under  the  influence 
of  peristaltic  waves,  severe  stretching  of  the  stomach  walls. 

This  conception  of  the  pathogenesis  of  the  pain  is  proved  by  the  fact 
that  the  belching  of  gas  or  thorough  emptying  of  the  stomach  contents 
through  copious  vomiting  immediately  cuts  short  the  phenomena  of  pain ; 
it  is  also  proved  by  the  frequent  and  synchronous  occurrence  of  balloon- 
like bulging  and  tension  of  the  epigastrium  (gastric  meteorism).  Again, 
it  is  proved  by  the  fact  that  phenomena  of  pain  are  found  first  and  fore- 
most with  those  cancers  which  spring  from  the  pylorus  itself  or  from 
its  immediate  vicinity. 

»  No.  35.  ''  No.  21.  "  Nos.  21,  27,  49,  50,   7(5. 


70  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Pain  produced  in  this  manner  seems  to  play  an  important  part  so 
long  as  there  is  no  extreme  and  permanent  dilatation  of  the  stomach  and 
so  long  as  the  intake  of  food  is  yet  sufficient ;  in  the  initial  stages  the 
persistence  of  HCl  secretion  might  also  be  a  factor  augmentating  the 
pain,  perhaps,  through  the  excitation  of  peristalsis  or  provoking  spasms 
of  the  pylorus. 

To  arrive  at  a  diagnosis  of  gastric  cancer  in  its  early  stages,  it  is 
essential  to  give  careful  consideration  to  the  pain  phenomena  which  have 
their  seat  in  the  epigastrium. 

The  frequent  false,  shameful  diagnoses  of  acute  or  chronic  gastritis 
in  gastric  cancer  will  become  fewer,  if  more  attention  is  paid  to  the  fact 
that  the  latter  affections  are  not  usually  accompanied  by  painful  phe- 
nomena. 

The  curve  of  pain-phenomena  during  the  course  of  cancerous  disease 
rises  in  the  beginning,  but  later  on  drops  often  to  zero,  which  is  in 
peculiar  contrast  to  the  underlying  anatomical  condition. 

Attacks  of  pain  which,  in  the  begiiming,  are  of  daily  occurrence, 
later  on  often  become  much  rarer  ^**  and  may  finally  disappear  entirely. 

This  might  be  explained  by  accommodation  of  the  stomach  through 
dilatation  to  the  raised  internal  pressure,  diminution  of  peristaltic  power 
and  a  reduced  intake  of  food,  as  well  as  the  gradual  cessation  of  HCl 
secretion. 

In  the  symptomatology  of  gastric  cancer  two  groups  of  pain-phe- 
nomena may  be  distinguished,  viz. : 

"Distention  Pains"   of   the   Stomach 

In  those  cases  where  pyloric  stenosis  has  occurred,  which  in  the  early 
stages  may  be  due  to  spasms,  the  pains  are  of  a  pronounced  colicky  na- 
ture and  are  identical  with  "colic  of  pyloric  stenosis"  as  described  by 
me.^*^ 

As  is  true  of  distention  pains  in  other  organs  (gall-bladder,  uterus, 
aorta),  it  is  also  the  case  here  that  with  increased  internal  pressure  there 
is  pronounced  tendency  to  radiation. 

Thus  different  types  of  pain  arise: 

1.  Eight-Sided  Type  ("pseudo  gall-stone  colic"). — The  pains  occur 
on  the  right  side  underneath  the  arch  of  the  ribs  and  radiate  spasmod- 
ically toward  the  right  loin  and  right  scapula. ^^ 

2.  ^^Girdle  pain^^  ^yp^- 

The  pains  begin  underneath  the  xiphoid  process  and  radiate  sym- 
metrically toward  both  sides,  along  the  arches  of  the  ribs,  into  the  flanks 
and  back  (51),  or  the  pains  converge  from  both  sides  toward  the  epi- 
gastrium. 

3.  Left-Sided  Type,-^  similar  to  gall-stone  colic. — The  pains  radiate 

"Nos.  11,  14. 

'*  R.  Schmidt,   Die  Schmerzphaenomene  bei   Inneren   Erkrankungen,  etc.     W.   Brau- 
niueller,   Wien   und    Leipzig.     Second   Edition,    1910. 
^»Nos.  11,  44,  58,  80. 
"  Nos.  56,  60,  68,  73,  83. 


CANCER    OF    THE    STOMACH  71 

from  the  epigastrium  toward  the  left  breast  and  into  the  left  scapula  and 
axillary  portions  of  the  left  side  of  the  thorax. 

■i.  Crossed  Type  (rare). — Radiation  from  the  right  side  beneath  the 
costal  arch  toward  the  left  scapula  or  the  reverse  (13,  61). 

As  with  all  pains  that  have  a  central  point  of  origin  and  peripheral 
extensions,  it  also  happens  in  these  cases  that  the  peripheral  extensions 
may  be  separated  from  the  ensemble  of  pain  and  occur  independently, 
which  renders  their  interpretation  difficult. 

Abortive  Pains 

Among  the  rather  infreqtcent  abortive  painful  conditions  the  follow- 
ing might  be  mentioned  according  to  their  topography : 

1.  Pains  in  the  back. 

Occasionally  they  can  be  elicited  experimentally  through  artificial  in- 
flation of  the  stomach,  and  accordingly  they  are  found  in  those  sponta- 
neous distentions  of  the  stomach-walls  which  frequently  exist  in  pyloric 
stenosis.  They  frequently  coincide  with  a  severe  sensation  of  pressure  an- 
teriorly in  the  epigastrium  and  occur  when  the  latter  become  maximally 
increased,  but  can  also  occur  by  themselves  (11,  57). 

Alimentary  provocation,--  and  hence  their  appearance  after  meals, 
distinguishes  them  from  those  continuous  pains  in  the  back  which  some- 
times accompany  retroperitoneal  glandular  metastases  and  involvement 
of  the  pancreas  from  cancer  of  the  stomach.  Pressure  on  the  gastric 
tumor  or  certain  movements,  such  as  sitting  up,  sometimes  lead  to  exacer- 
bations (15). 

2.  Vertebral  column. 

As  in  gastric  ulcer,  so  also  in  carcinoma  of  the  stomach,  we  may  elicit 
circumscribed  areas  of  tenderness  by  striking  the  vertebral  column  as  we 
do  in  percussion.  This  tenderness  may  be  intrascapular  (11)  or  on  a 
level  with  the  angle  of  the  scapula  (15)  or  correspond  to  the  twelfth 
dorsal  vertebra  (25). 

In  no  case  do  such  local  hyperesthesias  of  the  vertebral  column  alone 
justify  our  thinking  of  metastatic  involvement  of  the  same. 

3.  Pains  over  the  lower  third  of  the  sternum  (83)  or  to  the  left  of  it. 

4.  Right  or  left  lumbar  region. 

If  occasionally  there  be  isolated  pains  in  this  region  they  may  give 
rise  among  others  to  the  false  suspicion  of  a  renal  affection  (18,  63). 

5.  Lower  abdominal  regions  and  periumbilical  regions. 

This  kind  of  localized  pain  is  seldom  met  with  in  cancer  of  the  stom- 
ach; in  most  instances  it  might  be  attributed  to  secondary  disturbance 
of  the  bowel  or  peritoneal  complications  (4,  55). 


In  the  production  of  the  pain  phenomena  so  far  discussed  alimentary 
influences  show  themselves  clearly.     Precisely  for  the  correct  interpreta- 


"  No.  81. 


72  TUMORS    OF    THE    ABDOMINAL    VISCERA 

tion  of  the  last-named  isolated  radiations,  it  will  be  of  great  importance 
to  determine  in  how  far  they  are  dependent  on  alimentary  influences. 

If  the  pains  appear  immediately  after  eating  (46),  or,  as  frequently 
happens,  in  the  course  of  the  next  two  or  three  hours,  the  correct  in- 
terpretation will  not  be  difficult.  Often,  however,  the  interval  is  a  very 
long  one  (six  to  seven  hours),  which  is  probably  due  to  the  delayed  ex- 
pulsion of  stomach  contents  as  a  result  of  motor-insufficiency  (58,  72). 
In  no  case  does  such  a  state  of  affairs  justify  us  in  thinking  that  the 
neoplasm  is  situated  in  the  duodenum.  Not  infrequently  there  are  noc- 
turnal aggravations  of  these  complaints  which  is  in  line  with  the  tendency 
of  all  colicky  pains  to  appear  at  night. 

The  quality  of  food  is  not  without  consequence,  and  frequently  there 
exists  particular  intolerance  for  solid  foods,  especially  meat. 

Only  in  rare  cases  can  the  intake  of  food  allay  pain  (16).  This  is 
most  apt  to  be  the  case  with  milk,  etc.  (13),  or  if  the  food  stimulates  the 
stomach  to  empty  itself.  Thus  the  use  of  coffee  or  sour  wine  may  at 
times  afford  r-elief. 

Exquisite  hunger  pain,  similar  to  that  in  gastric  ulcer,  may  also  be 
observed. 

It  has  already  been  mentioned,  and  significance  attaclied  to  it,  that 
anything  which  unburdens  the  stomacli-walls,  such  as  belching  and  vom- 
iting, causes  alleviation  and  often  sudden  cessation  of  the  s^nnptoms  of 
pain  just  discussed. 

The  attitude  of,  as  well  as  the  changes  in,  the  position  of  the  body 
frequently  play  a  great  part,  especially  at  the  time  of  the  painful 
attacks. 

Thus  lying  on  the  right  side  often  causes  an  increase  of  pain  and  an 
increase  in  the  phenomena  of  regurgitation. 

This  behavior  is  exhibited  above  all  in  those  gastric  cancers  which 
have  involved  the  pylorus. 

In  cases  of  cancer  of  the  fundus  and  cardia,  lying  on  the  left  side  is 
badly  tolerated  (13,  45,  66),  and  even  otherwise  there  occasionalU^  exists 
severe  left-sided  pain  (66). 

A  c  company  in  g  Symptoms 

Of  the  symptoms  that  accompany  the  pain-phenomena  just  discussed, 
the  following  are  most  frequently  observed  according  to  their  mode  of 
origin : 

Active  gurgling  as  evidence  of  stenosis  due  to  spasm  or  occlusion ; 
hardening  of  the  epigastrium,  var3ang  increase  of  resistance,  especially 
underneath  the  left  border  of  the  ribs,  and  at  times  a  swelling  in  that 
area ;  all  of  these  being  manifestations  of  peristaltic  efforts  to  overcome 
the  obstruction  at  the  pylorus ;  furthermore,  hiccough,  eructation,  vomit- 
ing. A  rare  accompanying  symptom  is  defective  vision  during  an  attack 
of  pain  (26). 

The  pain  phenomena  hitherto  discussed  have  for  their  anatomical 
basis  ulceration  in  the  vicinity  of  the  pylorus. 

To  a  great  extent  they  proceed  from  the  mechanical  factor  of  dis- 


CANCER    OF    THE    STOMACH  73 

tention  of  the  stomach-walls  which  is  at  the  bottom  of  the  sensation  of 
pressure  in  the  stomach,  so  frequent  in  the  beginning  of  the  disease. 

They  are  frequently  found  in  the  early  stages  of  gastric  cancer,  and 
are  of  valuable  service  in  differentiating  from  such  painless  affections  as 
chronic  gastritis. 

But  they  may  also  afford  valuable  aid  in  differentiating  gastric  neu- 
roses that  are  accompanied  by  pain. 

With  reference  to  the  foregoing,  two  points  of  view  are  to  be  borne 
in  mind : 

1.  The  more  mechanical  factors,  such  as  position  of  the  body,  etc., 
take  part  in  the  production  of  gastralgia,  the  greater  the  probability  of 
ulcerative  disease. 

2.  Nocturnal  occurrence  of  gastralgias,  awakening  the  patient  from 
sleep,  is  generally  peculiar  to  organic  ulcerative  conditions. 


Even  though  a  consideration  of  the  pain  phenomena  does  not  in  and 
of  itself  lead  up  to  the  diagnosis  of  "gastric  cancer,"  it  w^ill  in  many  cases 
render  an  ulcerative  disease  probable. 

In  most  instances  the  diagnosis  of  an  ulcerative  condition  is  a  pre- 
requisite for  the  diagnosis  of  cancer  of  the  stomach,  at  least  in  that  phase 
of  the  disease  which  proceeds  without  positive  findings  on  palpation. 

Whilst  so  far  we  have  been  concerned  with  symptoms  of  pain  which 
often  occur  spontaneously,  after  the  manner  of  colics,  there  exist  also 
pains  which  can  be  mechanically  evoked,  especially  by  pressure  on  the 
epigastrium. 

T enderness  on  Pressure 

In  very  many  cases  of  cancer  of  the  stomach  the  epigastrium  is  sen- 
sitive to  pressure  even  in  the  first  stages  of  the  disease. 

As  in  gastric  ulcer,  the  cause  for  this  may  lie  in  the  intragastric  in- 
crease of  tension.  If  the  balloon-like  tense  stomach  is  brought  to  col- 
lapse through  copious  belching  of  gas  or  through  vomiting,  the  erstwhile 
pronounced  epigastric  tenderness  often  suddenly  disappears.  Evacua- 
tion of  the  bowels  also  seems  to  relieve  such  a  tense  ballooned  stomach 
occasionally. 

But  the  tumor-mass,  as  such,  may  also  be  the  point  of  origin  of  pain- 
ful sensations,  particularly  when  inflammatory  peritoneal  complications 
arise  which  may  occasionally  be  demonstrated  by  the  peritoneal  fric- 
tion rub. 

Localized  tenderness  on  pressure,  therefore,  always  deserves  atten- 
tion, and  may  sometimes  confirm  an  indistinct  finding  obtained  by  pal- 
pation. 

Where  we  are  dealing  with  movable  tumors,  the  point  of  tenderness 
will  vary  with  the  migrations  of  the  tumor.  The  wandering  and  pulling 
of  the  tumor  incidental  to  body  movements  may  produce  localized  pain, 
often  giving  rise  to  a  sensation  of  painful  turning  over. 

In  all  cases  Avhere  pa.lpation  does  not  yield  definite  findings,  such  sen- 


74  TUMORS    OF    THE    ABDOMINAL    VISCERA 

sations  should  be  carefully  considered,  especially  in  the  cases  of  intelli- 
gent patients. 

The  mechanical  trauma  of  pressure  which  goes  with  palpation  of  the 
epigastrium  may  a,lso  produce  pain  when  brought  about  in  another  form, 
as  in  straining  of  the  belly-walls  during  defecation  (40),  or  in  lifting 
heavy  burdens  (65),  or  by  pressing  against  a  load  when  carrying  it  (28). 

Setting  the  body  in  vibration,  as  happens  when  going  down  hill,  etc., 
must  be  taken  into  account  as  a  mechanical  factor.  Thus  even  motion 
may  occasionally  aggravate  the  pains ;  if  the  latter  be  localized  over  the 
lower  part  of  the  sternum,  it  might  lead  to  confusion  with  angina  pec- 
toris (43). 

So  far  it  has  been  pointed  out  that  cancerous  conditions  of  the  stom- 
ach not  seldom  announce  themselves  by  phenomena  of  pain  and  also  sub- 
sequently run  a  painful  course,  which  is  in  contradistinction  to  chronic 
gastritis  and  in  accord  with  benign  ulcerations  of  the  stomach. 

It  is  true  that  in  rai*e  cases  the  beginning  of  cancerous  disease  may 
be  signalled  by  the  disappearance  of  formerly  existing  painful  conditions. 
Thus  some  cases  of  gastric  ulcer  run  along  with  a  painful  feeling  of  hun- 
ger on  an  empty  stomach,  which  at  any  time  can  be  promptly  cut  short  by 
alkalies,  and  which  undoubtedly  is  due  to  excess  of  hydrochloric  acid  or 
hyperesthesia  from  hydrochloric  acid.  If  in  such  cases  there  develop  a 
cancer  having  the  ulcer  for  its  base,  it  may,  through  cessation  of  HCl 
secretion,  have  the  effect  of  a  permanently  administered  massive  alkalido- 
sis.  The  pains  disappear  (96),  and  in  this  way  an  apparent  improvement 
in  the  ailment  really  marks  the  beginning  of  the  lethal  disease. 

d.    Appetite,  Thirst  and  Tolerance  of  the  Stomach 

It  must  be  a  priori  evident  that  with  the  great  individual  differences 
of  gastric  function,  even  as  existing  within  physiological  limits,  cancerous 
disease  of  the  organ  will  manifest  great  variability  with  reference  to  ap- 
petite, feeling  of  thirst  and  tolerance  for  food. 

A  "stomach  athlete,"  a  "heavy  eater"  will  be  thrown  out  of  his  stride 
with  greater  force  when  cancer  takes  hold  of  his  functionally  powerful 
stomach  than  will  a  "stomach  weakling." 

Even  though  anorexia  may  be  the  rule,  exceptional  cases  are  fre- 
quently found  in  which  the  appetite  is  preserved,  and  even  meat  is  well 
tolerated.-^ 

Thus,  for  instance,  medullary  carcinoma  (8)  may  be  accompanied 
by  bvit  little  disturbance  of  appetite  at  a  time  when  the  tumor  has  at- 
tained enormous  size.  In  view  of  such  cases  one  would  be  tempted  to  say: 
The  greater  the  tumor  the  better  the  appetite  and  the  fewer  the  com- 
plaints. 

Absence  of  stenosis  because  of  rapid  ulceration  might  in  part  explain 
the  insignificance  of  the  complaints. 

Ea'cu  cases  of  gastro-colonic  fistula  may  run  along  with  a  relatively 
good  appetite  (31). 

"Nos.  3,  8,  11,  17,  2-2,  27,  33,  39,  56,  66,  69,  72,  77,  78,  81,  86. 


CANCER    OF    THE    STOMACH  75 

Not  infrequently  it  is  only  the  fear  of  suffering  that  induces  the 
patient  to  eat  little  (51,  66,  83). 

In  no  case,  therefore,  is  a  well-preserved  appetite  a  finding  which 
can  be  construed  against  the  diagnosis  of  cancer  of  tlie  stomach. 

Mention  deserves  to  be  made  of  the  fact  that  cancer  of  the  stomach 
may  make  its  debut  with  a  voracious  appetite.  This,  however,  is  extremely 
rare  and,  according  to  my  experience,  is  observable  in  neuropathic  in- 
dividuals only. 

Thirst 

The  demand  for  liquids  is  frequently'  increased  (1,  2,  8,  28).  This 
symptom  seems  to  me  to  deserve  attention,  since  in  gastric  neurosis,  which 
often  must  be  differentially  diagnosticated,  the  feeling  of  thirst  seems 
often  to  have  dropped  below  normal,  giving  rise  to  oligodypsy. 

Polydypsy  occurs  in  cases  of  cancer  that  progress  without  vomiting. 
Severe  anemia  seems  occasionally  to  be  a  favoring  factor,  analogous  to 
such  behavior  in  primary  anemias.  Sensations  of  heat  in  the  stomach 
sometimes  seem  to  provoke  the  feeling  of  thirst. 

Anofpxia 

If  in  cases  of  gastric  cancer  we  analyze  the  sensations,  that  we  term 
anorexia,  we  very  frequently  encounter  a  particular  aversion  toward 
meat,  and  oftenest  it  is  cooked  beef  that  excites  the  greatest  repugnance. 
This  anorexia  produced  by  meat  is,  however,  by  no  means  an  infrequent 
symptom  in  connection  with  other  lesions  of  the  stomach,  such  as  achylia 
gastrica,  peptic  ulcer,  etc.,  and  conditions  of  general  weakness  resulting 
from  tuberculosis,  anemia,  etc. 

It  is  evident  that  meat,  especially  unappetizing  cooked  beef,  makes 
the  greatest  demands  on  the  digestive  energy  of  the  stomach. 

Intohrance 

Accordingly,  the  intolerance  of  the  stomach  affects  meat  food  in  the 
first  place,  subjective  symptoms,  especially  feeling  of  pressure  in  the 
epigastrium,  resulting  from  its  use. 

The  consistence  of  the  food  plays  a  large  part,  hard  foods  particu- 
larly being  badly  tolerated. 

The  curve  of  tolerance  often  drops  rapidly,  and  soon  the  digestive 
power  is  able  to  cope  with  a  liquid  diet  only  (milk,  soup,  etc.). 

In  view  of  the  pronounced  individual  peculiarities  of  gastric  function 
there  can  be  little  wonder  if  the  above  general  rules  are  subject  to  numer- 
ous exceptions. 

Thus  the  tolerance  for  milk  is  extremely  variable,  even  under  physio- 
logical conditions.  Frequently  cancer  patients  cannot  tolerate  it  be- 
cause it  sours  and  causes  belching  gas.  Soup  also  is  not  always  well  borne 
(67,  73). 

Disgust  for  meat  may  be  absent  even  in  advanced  stages  (78).  Oc- 
casionally minced  meat  agrees  best  of  all  (77).  It  is  not  subject  to  fer- 
mentative   processes    to    the    same    extent    as    carbohydrates,    and   hence 


76  TUMORS    OF    THE    ABDOMINAL    VISCERA 

would  seem  indicated  in  those  cases  where  fermentative  processes  are 
actively  going  on. 

From  the  above  we  would  expect  that  occasionally  there  would  be 
decided  intolerance  for  foods  prepared  with  flour  and  yeast  (48,  66,  81). 

If  at  times  solid  food  is  better  tolerated  than  liquid  (76,  96),  it  may 
be  explained  by  the  more  compact  form  of  the  first  mentioned,  which  im- 
poses less  of  a  mechanical  burden  upon  the  stomach. 

By  way  of  a  resume,  I  would  like  to  emphasize  once  more  that  with 
regard  to  the  symptoms  just  discussed  great  caution  is  to  be  observed 
with  reference  to  their  diagnostic  worth;  individual  peculiarities  are 
decisive. 


PHYSICAL    EXAMINATION    FOR    GASTRIC    CANCER 

Since  in  the  vast  majority  of  cases  the  pyloric  orifice,  as  a  result  of 
its  topographical  relation  to  cancer  of  the  pylorus,  is  subjected  to  more 
or  less  spasms,  occlusion  from  swollen  mucous  membranes  or  direct  en- 
croachment on  the  lumen,  the  physical  examination  must  aim  to  find 
those  signs  which  can  be  construed  as  indications  of  disturbed  canali- 
zation. 

Balloon-Lil-e  Stomach 

The  phenomenon  of  a  "balloon-like"  stomach  may  pass  for  such  a 
symptom. 

The  abnormal  decomposition  of  stagnating  contents  produces  a  sort 
of  "spontaneous  inflation"  of  the  stomach,  the  relation  of  which  to  vari- 
ous subjective  symptoms  has  already  been  discussed  in  detail.  This  in- 
flation may  affect  the  right  or  left  portion  (26,  28)  in  greater  degree. 
To  what  extent  this  pathological  condition  of  the  organ  can  be  demon- 
strated either  by  palpation  alone  or  also  by  inspection  will  depend  on 
the  degree  of  infiltration  as  well  as  the  state  of  the  abdominal  mus- 
culature. 

With  little  inflation  and  good  tonus  of  the  abdominal  musculature 
the  finding  can  often  be  shown  by  palpation  onl3\ 

It  is  advisable  to  palpate  interruptedly,  especially  on  the  left  side 
under  the  arch  of  the  ribs,  having  the  fingers  in  extension  and  palpating 
perpendicularly  or  at  least  at  an  acute  angle  in  order  to  recognize  the 
stomach  in  its  inflated  state,  in  Avhich  it  much  resembles  a  cystic  forma- 
tion. With  a  relaxed  belly-wall  and  high  intragastric  pressure  one  will 
be  able  to  make  out  the  stomach,  which  appears  like  an  air-cushion. 
Pressure  on  same  often  immediately  produces  phenomena  of  regurgita- 
tion, such  as  belching  of  gas,  heartburn,  etc.  Through  the  upward  escape 
of  gas  in  belching,  the  inflated  stomach  collapses  like  a  punctured  balloon. 

Examination  by  succussion  very  often  elicits  loud  splashing  sounds. 

Visible  Gastric  Peristalsis 

Concomitant  with  the  symptom  of  "balloon  stomach"  we  frequently 
observe   visible   gastric    peristalsis,   the   peristaltic   waves    travelling   the 


CANCER    OF    THE    STOMACH  77 

extent  of  the  organ  accompanied  by  hiccough  (3,  5),  and  usually  with- 
out pain  (27,  50).  When  peristalsis  has  attained  its  height  there  fre- 
quently ensue  phenomena  of  regurgitation. 

Epigastric  Pulsation 

Among  the  findings  on  inspection  which  must  be  taken  into  considera- 
tion in  cases  of  gastric  cancer,  we  count  the  phenomenon  of  epigastric 
pulsation.  Tumor-masses  developing  in  the  epigastrium  and  spreading 
toward  the  spinal  column  frequently  come  into  contact  with  the  abdomi- 
nal aorta  and  often  pulsate,  this  phenomenon  sometimes  disappearing 
when  the  movable  tumors  are  displaced  on  changing  the  position  of  the 
body  (32).  Hence  in  determining  the  antero-posterior  dimensions  of 
such  an  epigastric  tumor  certain  significance  is  attached  to  the  presence 
of  pulsation. 

Without  a  palpable  tumor  epigastric  pulsation  is  not  of  diagnostic 
import.  It  can  frequently  be  found  in  connection  with  gastroptosis. 
The  "balloon  stomach"  above  referred  to  is  capable  of  transmitting  aortic 
pulsation  anteriorly.  Auscultatory  findings,  which  will  be  discussed  later, 
can  enhance  the  significance  of  epigastric  pulsation. 

Abscess  of  Ahdominal  Wall 

Abscesses  of  the  ahdominal  walls  count  among  the  findings  that  can 
be  easily  determined  by  inspection  in  cancer  of  the  stomach.  They  are 
very  rare,  occurring  most  frequently  with  those  gastric  cancers  that 
have  become  intimately  adherent  with  the  anterior  belly-wall."^ 

In  one  of  these  cases  (34),  at  the  summit  of  the  swelling,  there  ex- 
isted splashing  which  could  be  heard  and  felt,  pulsation,  and  tympanitic 
sound  when  lying  on  the  back,  which  gave  way  to  dulness  when  lying  on 
the  side.  This  sufficiently  identified  the  internal  origin  of  the  abscess 
and  excluded  the  danger  of  confusion  Avith  an  abscess  springing  from  the 
belly- walls  themselves. 

Hernias  in  the  Linea  Alba 

Among  the  most  frequent  findings  on  inspection  in  gastric  cancer 
we  count  those  hernias  made  up  mostly  of  preperitoneal  adipose  tissue 
and  being  the  size  of  a  pea  or  nut,  which  might  occasionally  be  taken  as 
the  cause  of  existing  stomach  complaints.  Otherwise  they  are  a  rather 
inconsequential  finding,  and  I  Avould  warn  explicitly  against  taking  them 
into  account  as  an  etiological  factor  in  stomach  complaints,  especially  if 
there  be  no  compelling  reasons  for  doing  so.  They  are  probabl}'^  pre- 
existent  in  cases  of  cancer,  appearing  more  prominently  on  account  of 
the  emaciation  of  the  abdominal  walls. 

Positive  findings  by  palpation  may  be  permanently  absent ;  this,  how- 
ever, applies  to  only  a  small  percentage  of  cases,  providing  the  proper 
technique  be  employed.  As  to  the  length  of  time  intervening  between 
ulceration  (demonstration  of  blood  in  the  feces)   and  palpability  of  the 

"  See  R.  Segfiel.  Uber  die  Milbeteiligung  der  vorderen  Bauchwand  beim  Magen- 
carcinom.      Miinchener    med.    Wochenschr.,    1899,    page    \(\\\. 


78  TUMORS    OF    THE    ABDOMINAL    VISCERA 

tumor,  there  are  present  no  certain  facts  for  one's  guidance;  naturally, 
there  will  be  great  variation. 

At  the  same  time,  it  is  more  than  probable  that  cancerous  disease  of 
the  stomach  reveals  itself  to  chemical  investigation  much  earlier  than  to 
physical  examination.  Some  of  the  causes  for  continued  latency  of  gas- 
tric tumors  would  be  : 

1.  Adhesions  to  the  lower  posterior  surface  of  the  liver. 

2.  Localization  in  the  immediate  vicinity  of  the  cardia. 

3.  Surface  infiltration. 

Palpation 

The  greatest  care  should  be  taken  in  palpating  the  line  between  the 
xiphoid  process  and  the  umbilicus.  Here  the  recti  are  often  split,  and 
we  do  not  have  to  contend  with  an  intervening  musculature.  The  ex- 
amination should  be  made  with  the  body  in  various  positions  (also  stand- 
ing), and  the  breathing  should  be  very  deep,  i.e.,  diaphragmatic."'  Only 
in  this  way  can  tumors  be  felt  that  are  concealed  behind  the  xiphoid 
process.  " 

One  should  never  omit  to  examine  with  the  body  on  the  right  side,  as 
in  palpation  of  the  spleen,  in  order  to  determine  tumors  which  are  lying 
in  the  left  hypochondrium. 

Spasms  of  the  Pylorus 

Tumors  belonging  to  the  pyloric  region  not  infrequently  display  a 
peculiar  behavior  in  that  their  consistence  often  undergoes  sudden  changes 
during  palpation,  frequently  accompanied  by  squirting  sounds.  The  pa- 
tients themselves  occasionally  are  aware  of  a  sudden  and  at  times  pain- 
ful occurrence  of  tautness  that  feels  like  a  cord,  which  again  disappears 
(6,  13,  20,  107)  ;  this  cord  may  have  the  circumference  of  the  index 
finger  (13). 

Nothing  would  be  wider  of  the  mark  than  to  infer  from  such  a  find- 
ing that  there  was  a  functional  spastic  disease  of  the  pylorus  (Kauss- 
maul). 

In  these  cases  we  are  usually  dealing  with  fibrous  and  scirrhus  forms 
of  gastric  cancer  accompanied  by  much  hypertrophy  of  the  pyloric  mus- 
culature.    That  which  is  felt  is  the  result  of  two  things: 

1.  Hypertrophied  musculature  which  is  in  a  state  of  peristaltic 
unrest,  and, 

2.  Cancer  mass.  It  is  upon  the  first  of  these  that  the  change  during 
palpation  depends. 

It  is  true  that  analogous  contractile  conditions  can  be  felt  in  the 
pyloric  region  of  the  stomach  in  cases  of  gastric  neuroses,  thus  among 
others,  in  achylia.  The  evidence  of  prompt  motility  and  a  constantly 
negative  blood  finding  in  the  feces  will,  however,  put  us  on  the  right  track 
in  these  cases,  which,  after  all,  are  extremely  rare. 

"  See  page  3. 


CANCER    OF    THE    STOMACH  79 

Tumor  Types 

Corresponding-  to  the  varied  localization  and  form  of  the  tumor- 
masses  tlie  different  types  of  gastric  cancer  may  be  distinguished  as 
follows : 

Globular,  Cyst-Like 

These  are  rounded,  often  quite  smooth  tumors  up  to  the  size  of  an 
apple,  which  not  rarely  cause  a  protuberance  of  the  belly-walls.  They 
are  similar  to  cystic  enlargements.^*' 

Situated,  as  a  rule,  to  the  right  of  the  median  line,  they  are  often 
best  felt  when  the  patient  is  lying  on  his  left  side. 

Its  identity  with  the  stomach  is  often  indicated  by  the  fact  that 
pressure  upon  tlie  tumor  produces  regurgitation  of  stomach  contents ; 
also  there  are  often  audible  loud  and  persistent  squirting  sounds  over 
the  tumor. 

Light  percussion  over  the  central  portions  of  the  tumor-mass  yields 
a  tympanitic  sound. 

Tumors  in  the  Begion   of  the  Spleen 

These  are  usually  knobby  and  much  harder  than  a  chronic  tumor  of 
the  spleen,  and,  with  the  patient  lying  on  his  right  side,  are  often  pal- 
pable only  at  a  point  where  otherwise  the  anterior  pole  of  an  enlarged 
spleen  is  demonstrable ;  in  the  erect  position  the  tumor  in  some  cases 
moves  downward  from  the  splenic  location  and  can  then  be  distinctly  felt, 
but  on  lying  down  disappears  again  behind  the  arch  of  the  ribs  (62). 
The  particular  hardness  of  cancerous  tumors  is  a  sufficient  mark  of  dis- 
tinction from  a  palpable  anterior  pole  of  the  spleen.  I  recall  a  case 
which  was  beset  with  difficulties :  on  the  left  there  was  a  malignant  pleu- 
ral effusion  ;  and  also  on  the  left  side  beneath  the  costal  arch  a  stony- 
hard  tumor  could  be  felt.  Autopsy  disclosed  the  anterior  pole  of  the 
spleen,  which  had  been  forced  dowTiward ;  the  peculiar  consistency  was 
due  to  massive  deposits  of  lime  salts  in  the  capsule  of  the  spleen. 

Cylindrical   Tumors  Lying 
Transversely 

This  tj'pe  is  counted  among  the  most  frequent,  and  includes  chiefly 
cancers  springing  from  the  pylorus  itself  or  from  its  immediate  vicinity 
in  the  lesser  curvature.  They  are  frequently  situated  in  the  median  line 
or  a  little  to  the  right  of  it. 

It  is  these  that  give  rise  to  the  phenomena  of  contraction  above  de- 
scribed.    They  are  mostly  fibrous  carcinomas. 

Surface   Tumors 

Tumors  extending  along  the  surface,  often  the  size  of  a  child's  head. 
At  times  these  have  the  umbilicus  for  their  central  point  and  are  occasion- 
ally adherent  to  the  anterior  abdominal  wall  (8). 

"  Thus  in  Case  33,  competent  surgical  opinion  prior  to  operation  was  to  the  efiFect 
that  there  was  a  possibility  of  a  cystic  swelling. 


80  TUMORS    OF    THE    ABDOMINAL    VISCERA 

They  are  mostly  medullary,  non-stenosing  carcinomas,  which,  there- 
fore, give  rise  to  but  few  gastric  manifestations.  It  is  in  these  cases  that 
the  paradox  applies :  the  greater  the  cancerous  tumor,  the  better  the 
appetite.     Frequently  there  is  pronounced  pulsation. 

Contracted  Stomach 

Stomach  contracted  and  felt  in  toto,  without  circumscribed  tumor- 
formations,  in  a  state  of  active  peristalsis.  This  type  is  found  in  those 
cases  which  in  the  literature  are  described  as  benign  gastric  affections: 
"linitis  plastica  Brinton,^''  but  whose  malignant  nature  is  now  generally 
recognized  (2). 


Tumors  originating  in  the  stomach  usually  possess  a  high  degree  of 
mobility. 

In  part,  these  changes  in  place  occur  spontaneously  without  our  co- 
operation, and  are  frequently  noticed  by  the  patients  themselves.  They 
will  give  the  information  that  without  changing  the  position  of  the  body, 
the  tumor  is  at  one  time  more  to  the  right  and  at  another  more  to  the 
left  (11,  44).  This  wandering  probably  depends  in  the  first  place  on  the 
state  of  fulness  with  occasional  spontaneous  inflation  of  tlic  stomach.  In 
case  of  doubt  as  to  whether  a  palpable  tumor  in  the  epigastrium  belongs 
to  the  liver  or  the  stomach,  the  phenomenon  of  spontaneous  wandering 
will  decide  against  the  former. 

These  tumors,  providing  they  have  not  become  firmly  adherent,  may 
also  be  displaced  actively,  only  their  movability  is  least  in  a  downward  di- 
rection analogous  to  an  object  suspended  from  above  (64,  90). 

If  the  tumor  can  be  well  grasped  from  above  it  is  possible  to  con- 
stantly locate  it  during  every  respiration,  but  if  such  is  not  the  case  the 
tumor  will  glide  away  from  luider  the  hand  during  expiration  and  move 
upward.     The  tumor  cannot  be  fixed  during  expiration. 

The  preceding  phenomenon  is  therefore  of  a  secondary  nature  and 
does  not  deserve  that  significance  which  is  generally  ascribed  to  it.  The 
physical  strength  of  the  examiner  would  be  more  than  a  sad  thing,  if  it 
were  not  sufficient  to  hold  the  tumor  even  during  expiration,  providing, 
of  course,  that  the  tumor  can  be  grasped  from  above.  Only  the  last  pos- 
sibility or  impossibility  is  of  diagnostic  interest  with  regard  to  free 
movability  or  adhesions. 

The  movability  can  be  indirectly  determined  by  having  the  patient 
assume  different  body  positions.  The  movability  in  this  way  often  proves 
very  great.-" 

Ballottement 

Ballottement  figures  among  the  rarest  findings  in  cancer  of  the  stom- 
ach (61);  enteroptosis,  left-sided  location  of  the  tumor  and  a  consider- 
able diameter  are  favoring  factors. 

"  Thus  in  Case  62,  the  tumor  is  found  behind  the  left  arch  of  the  ribs  with  the 
patient  on  his  back,  but  wanders  into  the  region  of  the  umbilicus  when  the  patient 
changes  to  his  right  side. 


CANCER    OF    THE    STOMACH  81 

In  many  cases  where  gastric  cancer  has  been  positively  diagnosed  and 
tumors  in  the  region  of  the  stomach  are  demonstrable,  other  rarer  pos- 
sibilities enter  into  our  calculations :  thus  we  may  be  dealing  with  infil- 
trated omentum  reflected  onto  the  upper  surface  of  the  liver  (94),  or 
with  groups  of  glands  along  the  lesser  curvature ;  there  also  come  into 
consideration  mesenteric  gland  metastases  (66),  and  naturally  also  me- 
tastases in  the  left  lobe  of  the  liver. 

Percussion 

Percussion  plays  a  rather  subordinate  part  in  the  determination  of 
gastric  tumors  ;  at  any  rate,  it  may  be  of  importance  in  differentiating 
cystic  tumors,  in  which  case  light  percussion  must  be  made  over  the 
central  portions  of  the  tumor-mass,  having  the  finger  or  pleximeter  in 
firm  apposition.  If  the  result  be  a  completely  tympanitic  sound,  it  is 
always  possible  that  the  tumor  springs  from  some  air-containing  organ 
(stomach  or  gut). 

With  the  presence  of  pyloric  stenosis  or  dilatation  of  the  stomach, 
the  liver  dulness  is  frequently  more  or  less  diminished  and  in  its  place 
we  find  a  tympanitic  sound. 

Percussion  may  also  be  employed  for  detecting  abdominal  areas  that 
are  tender  to  pressure  and  to  blows.  Where  we  have  to  determine  whether 
the  cause  producing  the  pain  is  deeply  or  superficially  situated,  percus- 
sion becomes  of  differential  diagnostic  significance  (61). 

Auscultatory  Findings 

Among  the  findings  on  auscultation,  splashing  sounds  as  signs  of  dila- 
tation due  to  pyloric  stenosis  deserve  attention  in  those  cases  where  they 
are  present  in  the  morning  on  an  empty  stomach  (22),  or  where  they  can 
be  obtained  at  almost  any  time  and  with  ease.  It  is  always  advisable  to 
elicit  this  phenomenon  after  the  manner  of  Hippocratic  succussion  by 
grasping  the  right  and  left  sides  of  the  pelvis  and  shaking. 

Gastric  Borhorygmi 

Completely  analogous  to  intestinal  borborygmi  occurring  in  stenosis 
of  the  bowel,  there  may  also  occur  similar  auscultatory  phenomena  (gas- 
tric borborygmi)  with  stenosis  of  the  pylorus.  If  of  but  slight  inten- 
sity, they  can  be  heard  only  when  the  ear  is  applied  to  the  epigastrium, 
but  later  on  frequently  become  audible  at  a  distance  and  are  noticed  by 
the  patient  himself.  The  more  they  are  found  to  be  present  and  the 
louder  they  become,  the  greater  should  be  the  attention  given  them  as  an 
expression  of  pyloric  stenosis.  Their  occurrence  may  be  considerably  in 
advance  of  the  characteristic  objective  symptoms  of  pyloric  stenosis. 

Peritoneal  Friction-Sounds 

Among  the  phenomena  of  auscultation  peritoneal  friction  deserves 
very  careful  attention  (9,  18)  ;  if  limited  to  the  epigastrium,  it  is  most 
frequently  due  to  perigastric  or  perihepatic  complications  (ulcerating 
gastric  cancer  and  liver  metastases).     I  have  never  been  able  to  observe 


82  TUMORS    OF    THE    ABDOMINAL    VISCERA 

it  in  cases  of  gastric  ulcer.     Frequently  recognizable  on  palpation  by  its 
crepitating  sound,  it  is  much  increased  by  diaphragmatic  breathing. 

'More  frequent  are  these  systolic  murmurs  heard  in  the  epigastrium, 
mostly  in  a  circumscribed  area,  whose  genesis  is  not  perfectly  clear  but 
whose  origin  is  in  the  circulation.-^  I  believe  that  I  was  the  first  to  empha- 
size the  peculiarity  of  their  expiratory  increase.-'"*  They  are  found  in 
gastric  as  well  as  hepatic  cancer. 

They  seem  to  have  four  rules  in  common : 

1.  Their  occurrence  is  synchronous  with  the  arterial  pulse  or  if,  as 
is  exceptionally  the  case,  they  are  constant,  there  is  a  pronounced  sys- 
tolic increase. 

2.  At  the  end  of  expiration  they  gain  in  intensity  and  occasionally 
are  clearly  demonstrable  then,  only  if  at  this  time,  i.e.,  the  end  of  expi- 
ration, the  patient  holds  his  breath. 

3.  They  are  usually  confined  to  a  small  area. 

4*.  Firmer  apposition  of  the  stethoscope  usually  increases  the  inten- 
sit}'^  of  the  murmurs ;  in  rarer  cases  they  become  audible  onl}^  when  the 
stethoscope  is  applied  with  pressure.  In  most  instances  they  can  be  made 
out  without  any  piressurc  by  simply  applying  the  ear. 

"Epigastric  circulator}^  murmurs,"  aside  from  the  extremely  rare 
cases  of  aneurysm  of  the  abdominal  aorta,  really  come  into  consideration 
only  in  Laetmec  cirrhosis,  and  even  here  they  are  rare  enough. 

At  times,  therefore,  practical  significance  attaches  to  them  as  indica- 
tors of  malignant  growths  in  the  abdomen,  regardless  of  the  theoretical 
question  as  to  their  cause. 

They  may  be  of  especial  value  in  those  cases  which  yield  obscure  find- 
ings on  palpation. 

Their  pathogenesis  is,  perhaps,  not  a  uniform  one.  If  the  epigastric 
tumor  is  lying  upon  the  abdominal  aorta  (cancer  of  the  pancreas),  one 
could  imagine  that  pressure  upon  same,  especially  if  reinforced  by  pres- 
sure with  the  stethoscope  from  the  outside,  would  produce  a  mild  stenosis 
of  the  abdominal  aorta  which  would  give  rise  to  a  systolic  murmur.  Dur- 
ing expiration  the  antero-posterior  diameter  of  the  epigastrium  is  small- 
est, the  belly-wall  is  nearest  to  the  vertebral  column,  and  with  the  inter- 
position of  a  tumor  the  conditions  for  compression  of  the  aorta  would 
be  most  favorable. 

However,  this  explanation  will  not  obtain  in  those  cases  of  cancer 
metastases  in  the  right  lobe  of  the  liver  where  the  murmurs  are  audible 
over  the  infiltrated  area,  and  there  only  (46,  59,  82).  In  the  latter  case 
we  can  only  take  into  consideration  compression  of  the  larger  venous  or 
arterial  trunks,  and  in  those  cases  in  which  there  are  present  constant 
murmurs  becoming  increased  during  systole,  the  origin  is  most  likely  in 
the  venous  current. 

=»  Nos.  2,  8,  11,  13,  37,  47,  53,  62,  63,  64,  65,  73,  78,  86,  98. 
^'  Med.  Klin.,  1909,  No.  2. 


CANCER    OF    THE    STOMACH  83 


ACCOMPANYING    SYMPTOMS    FROM    OTHER    ORGANS 

These  will  be  discussed  here  in  so  far  only  as  they  are  more  or  less 
peculiar  to  carcinoma  of  the  stomach.  Their  relation  to  malignant  dis- 
ease in  general  has  already  been  discussed  in  another  place  (page  37). 

Particular  consideration  will  here  be  given  to  those  findings  which 
may  occasionally  appear  as  early  symptoms. 

Oral  Cavity 

There  can  be  no  wonder  that  such  a  far-reaching  process  as  malig- 
nant disease  of  the  stomach  should  make  itself  felt  throughout  the  entire 
digestive  tract. 

Atrophy  of  Lingual  Mucosa 

As  worthy  of  note  I  consider  those  atrophic  alterations  of  the  lin- 
gual mucosa  which  up  to  the  present  time  have  received  but  little  atten- 
tion. In  these  cases  the  mucosa  is  partially  (especially  in  its  middle  por- 
tion) or  entirely  smooth,  shiny,  and  "paper-like" ;  '^'^  similar  atrophic 
conditions  are  not  infrequently  met  with  in  pernicious  anemia,  but  in  the 
latter  case  they  are  often  accompanied  by  the  formation  of  painful  blis- 
ters, which  is  of  rare  occurrence  in  connection  with  gastric  cancer. 

Coated   Tongue 

Coated  tongue  is  an  inconstant  finding,  being  notoriously  frequent  in 
neuropathic  individuals  without  any  appreciable  digestive  disturbances, 
and  may  be  entirely  absent  even  in  advanced  cases  of  gastric  cancer.  In 
some  cases  this  may  be  explained  by  the  atrophic  processes  of  the  lingual 
mucosa  above  referred  to,  as  in  the  latter  case  decided  desquamation  of 
the  atrophic  epithelial  layers  does  not  take  place. 

This  may  also  explain  why  occasionally  the  coating  of  the  tongue  is 
unilateral  only,  there  being  atrophy  of  the  mucosa  on  the  other  side. 

Teeth,  etc. 

Very  defective  teeth,  tendency  to  the  formation  of  tartar,  and  a  bad 
condition  of  the  oral  cavity  in  general  are  frequent  findings.  In  so  far 
as  these  conditions  favor  the  development  of  abundant  bacterial  growths 
and  the  foods  reach  the  stomach  after  most  imperfect  mastication,  we 
might  in  some  cases  consider  them  as  predisposing  factors  of  cancerous 
disease. 

Salivation,  Deglutition  Dijflculties 

Salivation  may  at  times  become  a  prominent  symptom  (9T).  Diffi- 
cult deglutition — mostly  of  mild  degree — may  occur  especially  in  those 
cases  where  we  are  dealing  with  a  diffuse  infiltrating  scirrhus  cancer  (10) 
or  where  the  cancer  development   originates  in  the  fundus. 

">See  Nos.  8,  10,  14,  23,  38,  41,  59,  69. 


84  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Intestinal  Tract:   Obstipation 

Obstipation  figures  among  the  most  frequent  accompanying  symptoms 
on  part  of  the  intestine ;  or  the  evacuation  of  the  bowel  may  be  irregular, 
obstipation  alternating  with  diarrhea. 

Diarrhea 

Cases  that  run  along  with  diarrhea  and  are  otherwise  suspicious  of 
cancer,  not  seldom  turn  out  to  be  pernicious  anemias. 

In  passing  it  may  be  mentioned,  that  diarrheas  may  sometimes  be 
initially  produced  by  hemorrhage  into  the  bowel  (67,  76). 

In  later  stages  of  the  disease  profuse  diarrhea  may  also  be  due  to 
disintegration  of  the  neoplasm  or  its  transmission  to  the  colon  with  the 
establishment  of  a  gastro-colic  fistula  (18,  31,  54). 

Obstipation    as   an   Early   Symptom 

Obstipation  may  be  put  down  as  the  rule  in  the  early  stages  of  gas- 
tric cancer  as  also  in  its  subsequent  course.  It  may  be  the  first  symptom 
of  a  developing  gastric  cancer  and  precede  all  other  symptoms.  When 
unaccountable  obstipation  occurs  in  individuals  who  have  previously  al- 
ways had  good  bowel  action  we  must  take  into  account  etiologically  the 
possibility  of  cancer,  and  among  other  things  institute  chemical  tests  for 
occult  blood  in  the  feces.  The  presence  of  large  fecal  masses  in  the  sig- 
moid flexure  should  constantly  remind  us  of  the  possibility  of  gastric 
cancer  (100). 

With  reference  to  the  pathogenesis  of  this  kind  of  obstipation,  it  is  an 
interesting  observation  that  gastro-enterostomy  may  entirely  remove  it. 
Accordingly,  we  are  no  doubt  concerned  with  "stomachal  obstipation." 

Intestinal  Peristalsis 

Mild  intestinal  peristalsis,  limited  to  the  lower  abdominal  region  and 
occurring  above  Poupart's  ligament,  is,  according  to  my  observation, 
not  a  rare  finding  ^^  in  those  cases  which  run  along  with  rigidity  of  the 
stomach,  even  though  there  be  no  anatomical  hindrance  within  the  bowel. 
Possibly  we  are  here  dealing  with  some  kind  of  associated  movement  of  the 
intestine. ^- 

In  other  cases  pronounced  intestinal  stenosis  may  be  present  in  the 
rectum,  dependent  upon  peritoneal  metastases  in  the  pouch  of  Douglas, 
as  in  Case  10  (scirrhus),  in  which  a  stenosis  was  demonstrable  4  cm  above 
the  anus,  and  in  Case  92,  which  presented  the  clinical  picture  of  bowel 
stenosis. 

This  rectal  type  of  gastric  cancer  frequently  is  accompanied  by  ascites 
resulting  from  carcinoma  of  the  peritoneum. 

There  is  danger  of  mistaking  carcinoma  of  the  rectum,  unless  atten- 
tion be  paid  to  the  intact  condition  of  the  mucosa  that  overlies  the  tumor- 

"Nos.    11,    14,   36,   39,   85,    100. 

^^  In  reviewing  tiie  literature  in  connection  with  the  publication  of  this  work,  I 
found  a  notice  in  regard  to  this,  which  is  in  accordance  with  my  observations.  See 
Anschiitz,  Mitt.  aus.  d.    Grenzg.  d.  Med.  u.  Chir.,  Ill  Supplement  b.,  1907,  page  516. 


CANCER    OF    THE    STOMACH  85 

masses  producing  stenosis  from  without.     The  diagnosis  might  also  re- 
solve itself  by  left-sided  supraclavicular  glandular  metastases. 

In  cases  of  subphrenic  suppuration  as  a  result  of  gastric  cancer,  in- 
flammator}'  adhesions  may  lead  to  intestinal  peristalsis  (7).  Pronounced 
meteorism  may  be  due  to  retroperitoneal  gland  metastases  (60,  66). 

Peritoneum 

The  peritoneum  may  become  altered  through  local  inflammation  in 
the  region  of  the  tumor-mass  and  give  rise  to  fibrinous  exudation,  which 
is  occasionall3'  demonstrable  as  peritoneal  friction  (leathery  rub). 

Juvenile  forms  of  gastric  cancer  tend  to  general  distribution  over  the 
peritoneum. 

Thus  I  saw  a  case  of  general  carcinosis  of  the  serous  membranes  in 
an  18  year  old  girl;  point  of  origin:  medullary  carcinoma  of  the  greater 
curvature  (autopsy). 

In  such  cases  there  is  the  constant  danger  of  erroneously  diagnosing 
tubercular  serositis,  which  may  be  even  the  anatomist's  verdict  at  the  first 
hasty  glance. 

Aside  from  the  above,  we  find  that  diffuse  infiltrating  scirrhus  cancers 
of  the  stomach  (so-called  linitis  plastica  Brinton)  frequently  give  rise  to 
metastases  in  the  peritoneum. 

Ascites 

A  fairl}^  constant  accompanying  symptom  of  carcinosis  of  the  peri- 
toneum is  ascites  (12,  51),  which  is  mostly  of  hemorrhagic  or  "milky" 
character ;  the  latter  condition  is  peculiar,  especially  to  those  cases  which 
run  along  with  extensive  mesenteric  and  retroperitoneal  glandular  metas- 
tases (85). 

Leaving  aside  the  hydropic-anemic  forms,  ascites  in  connection  with 
gastric  cancer  may  also  be  due  to  engorgement  of  the  portal  vein  in  con- 
sequence of  metastases  in  the  liver. 

Subphrenic  Abscesses 

Among  the  inflammatory  complications  we  might  emphasize  the  occa- 
sional occurrence  of  left-sided  subphrenic  abscess :  ^^  much  tenderness  to 
pressure  below  the  left  arch  of  the  ribs  and  in  the  lateral  portions  of  the 
lower  intercostal  spaces  of  the  left  half  of  the  thorax  with  occasional 
transition  of  the  process  to  the  left  pleura. 

If  in  the  final  stages  of  gastric  cancer  there  occurs  peritonitis  due  to 
perforation,  it  is  usually  manifested  by  chills,  sudden  collapse,  and  great 
tenderness  of  the  abdomen. 

Liver 

A  rather  severe  icterus  figures  among  the  rare  occurrences  in  connec- 
tion with  gastric  cancer. ^^  Secondary  cancer  of  the  liver  usually  runs 
its  course  without  icterus. 

"Nos.  7,  18,  34. 

'Mn  124  cases  under  my  own  observation,  I  find  icterus  only  twice;  in  one  case 
there  was  cancerous  infiltration  of  lig.  liepato-duodenale,  in  the  other  there  were  metas- 
tases in  the  liver. 


86  TUMORS    OF    THE    ABDOMINAL    VISCERA 

If  in  connection  with  symptoms  that  are  suspicious  of  cancer  there 
also  exists  a  distinct  icterus,  it  will  always  be  commendable  to  take  into 
consideration  the  possibility  of  pancreatic  or  duodenal  carcinoma. 

Hepatic  enlargement  and  increase  in  the  consistency  of  the  liver  may 
be  dependent  upon  fatty  infiltration  (31). 

One  should  be  cautious  in  attributing  unevenness  of  the  liver  surface 
to  metastases,  as  it  may  be  due  to  corset  lobe  formation  (64). 

Whilst  the  formation  of  metastases  in  the  liver  may  run  along  with- 
out pain,  there  are  on  the  other  hand  cases  in  which  such  intense  painful 
phenomena  set  in  that  one  may  be  led  to  suspect  cholecystitis,  abscess 
of  the  liver,  etc.,  especially  if  accompanied  by  fever  (46). 

If  the  metastases  have  occurred  in  the  left  lobe  of  the  liver  and  cause 
a  displacement  of  the  border  downward,  it  may  easily  happen  that  the 
tumor-mass  lying  under  the  supposed  elongation  of  the  right  lobe  of  the 
liver  may  be  mistaken  for  the  tumor  itself. 

Circulatory  System 

The  occasional  local  relations  to  the  circulation  and  the  resulting 
auscultatory  phenomena  have  already  been  discussed  in  another  place 
(page  81). 

Bradycardia  is  not  an  altogether  too  seldom  finding,  at  least  in  those 
cases  of  cancer  of  the  stomach  which  exhibit  a  tendency  to  exsiccation 
of  the  tissues,  and  in  which  the  blood  findings  may  be  more  or  less  nor- 
mal (3).  In  these  cases  there  are  usually  underlying  rather  fibrous  fonns 
with  stricturing  of  the  pylorus.  By  way  of  mummification  there  results 
a  reduction  of  cardiac  motor  force  with  consequent  atrophy,  and  this, 
together  with  a  state  of  inanition  and  secondary  general  weakness  of 
organs,  seems  to  me  the  most  frequent  cause  of  occasional  bradycardia.^^ 

In  the  anemic-hydropic  type  of  gastric  cancer  (23)  there  is  mostly 
present  tachycardia  with  venous  noises  ^^  and  anemic  heart  murmurs.  In 
addition  there  may  often  occur,  especially  over  the  sternum,  decidedly 
rasping  and  grating  systolic  murmurs,  which  even  autopsies  have  not 
been  able  to  account  for,  and  which  might  be  put  down  clinically  as 
pseudo- pericardial  nmrmurs. 

From  my  own  experience  I  would  regard  valvular  lesions  (post-endo- 
carditic)  as  extremely  rare  complications  of  malignant  neoplasms.  Per- 
haps this  may  be  explained  by  the  rarity  of  infectious  diseases  in  the 
previous  history  of  cancer  patients.'^*'* 

Atheromatous  changes  in  the  arterial  system,  peripheral  as  well  as 
central,  are  of  frequent  occurrence  (1,  7).  Thus  I  can  remember  cases 
of  youthful  individuals  who  showed  very  pronounced  atheromatous 
changes  (9,  38). 

In  Case  38  severe  constant  pains  in  the  large  toe  were  due  to  endar- 
teritic  process  in  the  anterior  tibial  artery. 

^=  Nos.  3,  25,  35,  49,  50. 

'«Nos.  19,  28,  51,  fi3,  71. 

^a  i?.  Schmklf.  Krebs  mid   Tnfectionski'ankheiten.     IMed.  Klinik,   1910. 


CANCER    OF    THE    STOMACH  87 

Those  capillai-y  dilatations  in  the  cheeks,  so  often  seen  in  patients 
who  have  arteriosclerosis  with  hypertension,  are  frequently  met  with  in 
cancer  patients. 

Thrombosis  of  the  crural  veins  (8,  73)  are  frecjuent  accompani- 
ments in  the  later  stages  of  the  disease;  it  will  be  well  to  bear  this  in 
mind  when  there  is  pain  in  the  lower  extremities,  e.g.,  in  the  calves,  to- 
gether with  unilateral  or  symmetrical  edema  (4)7). 

As  a  curiosity  I  will  mention  a  case  in  which  (via  ductus  thoracicus.^) 
there  occurred  thrombosis  of  the  left  subclavian  vein. 

In  a  small  percentage  of  cases  intumescence  of  the  spleen  may  occur, 
but  it  rarely  extends  below  the  arch  of  the  ribs.  These  are  cases  that 
are  accompanied  by  rather  severe  anemia,  and  the  tumor  may  be  desig- 
nated an  anemic  tumor;  moreover,  I  have  seen  splenic  tumors  in  cases  in 
which  the  cancer  of  the  stomach  developed  in  the  hilum  of  the  spleen 
(66),  Avhich  would  lead  us  to  think  of  local  congestion  resulting  from 
pressure  on  the  splenic  vein  as  the  cause  of  the  condition. 

Atrophy  of  the  spleen  is  of  much  more  frequent  occurrence  than 
enlargement. 

It  may  be  put  down  as  a  diagnostic  axiom  that  when  there  is  sus- 
picion of  gastric  cancer  and  the  spleen  is  distinctly  enlarged,  the  first 
thouglit  should  be  of  pernicious  anemia. 

Lympliatic  System 

In  cases  where  gastric  cancer  is  suspected,  one  should  never  omit  to 
examine  the  left  supraclavicular  space,  and  also  the  left  axilla.  It  is 
true  in  advanced  cases  only  do  we  find  "Virchow's  gland"  above  the 
clavicle,  and  even  then  the  percentage  of  positive  findings  is  not  large. 
They  coincide  almost  constantly  with  retroperitoneal  glandular  metas- 
tases, and  are  mostly  hard,  indolent  glands. 

I  can  recall  but  one  single  case  of  gastric  cancer  in  which  the  glands 
were  of  soft  consistence,  the  patient  being  30  years  of  age  (89). 

Quite  exceptionally  there  may  occur  inflammatory,  and  even  purulent, 
processes  in  the  glands  in  which  metastases  have  taken  place  (79,  105), 
and  possibly  the  infectious  agents  are  carried  in  by  way  of  the  thoracic 
duct  at  the  same  time  with  the  cancer-cells. 

However,  there  may  be  pre-existent  disease  such  as  tuberculosis,  and 
then  it  is  possible  to  demonstrate  anatomically  both  processes  side  by 
side. 

Metastases  into  the  right  supraclavicular  space  are  among  the  great- 
est rarities,  and  I  can  remember  but  one  such  case  (43). 

Tuberculous  lymphomas  of  the  neck  are  sometimes  also  of  extremely 
tough  consistence,  yet  they  are  seldom  strictly  unilateral,  often  recurring 
in  large  numbers,  and  extend  upward  along  the  neck.  Very  frequently 
the  history  is  decisive  (many  years'  duration)  ;  at  times  we  can  also 
find  scars  after  suppuration. 

Caution  must  be  observed  not  to  confuse  carcinomatous  glands  of  the 
neck  with  laterally  situated  calcified  strumous  nodules. 

The  latter  have  an  angular  surface  feel  and  arc  of  bony,  hard  con- 


88  TUMORS    OF    THE    ABDOMINAL    VISCERA 

sistence:  two  findings  which  will  perfectly  safeguard  the  differential 
diagnosis. 

I  have  never  observed  metastases  in  the  inguinal  glands.  Very  ex- 
ceptionally I  have  seen  inflammatory  swelling  in  connection  with  second- 
ary purulent  processes  in  the  pouch  of  Douglas  (7).  The  palpable 
tumor-masses  present  in  the  epigastrium  in  cases  of  gastric  cancer  not 
seldom  owe  their  existence  to  gland  metastases  (60)  ;  with  retroperi- 
toneal extension  they  may  even  lead  to  compression  of  the  aorta,  and 
thus  give  rise  to  murmurs. 

Diffuse  bone  metastases  may  run  a  perfectly  latent  course.  When 
making  direct  examination  for  bone  tenderness,  however,  it  will  fre- 
quently be  possible  to  elicit  positive  findings  in  such  exposed  parts  as 
the  sternum,  ribs,  pelvic  bones,  and  in  this  way  gain  information  which 
will  strengthen  the  suspicion  of  metastases  into  these  parts   (Tl). 

I  recall  a  case  of  suspected  osteosarcoma  of  the  right  trochanter, 
in  which  autopsy  disclosed  a  gastric  cancer  as  the  primary  focus. 

Genito-Urinary  System 

Polyuria,  with  the  quantity  of  urine  ranging  between  2,000  and  3,000 
cm^,  not  infrequently  accompanies  the  anemic  forms  of  gastric  cancer 
(8,  65,  84),  even  during  part  of  the  dropsical  stage;  in  these  cases  we 
are  dealing  mostly  with  medullary,  non-stenosing  forms.  Here  the  poly- 
uria is  to  be  interpreted  as  anemic  poh'uria,  which  is  also  found  in  severe 
chlorosis  or  pernicious  anemias. 

Case  54  is  characteristic:  without  the  administration  of  a  diuretic, 
there  was  a  sudden  diuresis  of  51,  with  simultaneous  retrogression  of 
the  edema. 

Case  90  illustrates  the  possibilit}'  of  a  confusion  with  renal  and  gas- 
tric tumors. 

Metastases  into  both  ovaries  (71,  72,  74),  mostly  bilateral,  is  not  a 
very  rare  complication ;  in  most  cases  there  is  coexistence  of  ascites 
as  a  result  of  carcinomatosis  of  the  peritoneum. 

Thus  there  mav  come  to  exist  a  gynecological  type  of  gastric  cancer 
and  the  ovarian  findings  may  be  the  occasion  for  useless  operations. 

Occasionally  it  also  happens  that  the  symptoms  of  an  incipient  gas- 
tric cancer  are  referred  to  some  accidental  tumor  of  the  genitalia  which 
bears  no  relation  to  the  cancer,  and  in  this  Avay  also  operations  are 
undertaken  on  the  strength  of  false  suppositions  (71). 

The  genesis  of  pleural  complications  may  be  manifold.  Thus  there 
may  be  inflammatory  pleural  effusions  in  connection  with  subphrenic 
abscesses  (7),  accompanied  by  much  tenderness  on  pressure  in  the  inter- 
costal spaces ;  hemorrhagic  exudations  are  frequently  found  with  diffuse 
infiltrating  scirrhus  forms  with  ascites,  and  in  youthful  individuals  they 
can  easily  arouse  false  suspicion  of  tubercular  serositis. 

Aspiration  after  operation  may  lead  to  gangrene  of  the  lung,  and 
thus  to  sanious  exudate  (55). 

Pleural  complications  almost  throughout  belong  to  the  later  stage  of 


CANCER    OF    THE    STOMACH  89 

gastric  cancer;  when  pleural  effusions  accompany  the  beginning  of  can- 
cer development  the  etiology  nmst  be  sought  for  in  other  directions. 

Thus  in  Case  92,  in  addition  to  gastric  cancer,  there  was  present  a 
right-sided  tubercular  pleuritis. 

Among  the  findings  that  affect  the  parenchyma  of  the  lungs  mention 
must  be  made  of  the  frequent  occurrence  of  atelectasis  in  the  left  lower 
lobe.  The  same  can  be  associated  with  the  oft-existing  dilatation  of  the 
stomach,  and  occasionally  with  carcinomatous  infiltration  of  the  dia- 
phragm. The  pulmonary  parenchyma  may  also  become  the  seat  of 
miliary  metastases,^"  presenting  the  clinical  picture  of  a  miliary  tuber- 
culosis minus  the  infectious  elements.  Thus  in  Case  95  there  was  present 
extreme  air-hunger,  together  with  a  slight  left-sided  hemorrhagic  effu- 
sion, microscopic  examination  of  which  gave  reason  to  suspect  malig- 
nancy. During  life  the  diagnosis  of  pulmonary  carcinomatosis  had 
been  made. 

Nervous   System 

Contracted  pupils  and  tardy  reaction  to  light  are  not  infrequent 
findings ;  together  with  rigidity  of  the  vessels  of  the  iris  they  may  appear 
as  an  accompanying  manifestation  of  a  general  angiosclerosis. 

In  some  cases  insomnia  is  prominent  even  in  the  initial  stages  with- 
out being  dependent  upon  pain  or  similar  causes. 

The  painful  phenomena  evoked  by  the  local  condition  have  already 
been  discussed  in  detail  elsewhere  (page  69). 

Furthermore,  many  complications  such  as  metastases  in  the  liver, 
endarteritic  processes  (38),  venous  thromboses,  metastases  in  bones, 
perforative  peritonitis,  etc.,  can  give  rise  to  intense  pain. 

As  a  curiosity  I  would  like  to  cite  a  case  of  streptococcic  meningitis 
(54),  in  which  the  bacteriology  furnished  ground  for  suspecting  intes- 
tinal origin  of  the  excitant  of  the  disease ;  an  unimpaired  sensorium  was 
clinically  striking. 

Tetanic  attacks  are  among  the  greatest  rarities  in  connection  with 
pyloric  stenoses. 

Shin 

Edematous  alterations  in  the  subcutaneous  connective  tissue  may 
often  be  permanently  absent.  With  fibrous  and  scirrhus  forms  of  car- 
cinoma of  the  stomach  there  may  even  result  a  sort  of  mummification  of 
the  organism. 

Opposed  to  this  are  the  dropsical  types  whose  external  aspect  stimu- 
lates the  picture  of  an  acute  nephritis ;  in  these  cases  there  are  often 
present  general  edemas,  even  in  the  region  of  the  sternum,  belly-wall, 
eyelids,  etc.     Here  we  are  concerned  mostly  with  medullary  forms. 

When  there  is  suspicion  of  carcinoma  we  must  always  be  on  the  look- 
out for  the  presence  of  edemas ;  especial  attention  should  be  given  to  the 
region  behind  the  internal  malleolus  and  over  the  sacrum. 

"  See  H.  Lippman.  Uber  einen  Fall  von  akuter  haematogener  Carcinomntose. 
Zeitschr.  f.  Krebsf.,  Bd.  Ill,  page  290. 


90  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Occasionally  the  edemas  are  latent,  appearing  only  after  protracted 
walking  or  after  a  hot  foot-bath. 

The  gravisli  pale  color  of  the  face  reminds  us  to  a  certain  extent 
of  the  appearance  of  the  tubercular  patients,  and  being  partly  yellowish 
it  bears  resemblance  to  the  color  seen  in  pernicious  anemia. 

As  not  only  bilirubin,  but  also  urobilinogen,  is  frequently  absent  from 
the  urine,  there  is  no  evidence  for  the  hepatic  oi'igin  of  this  color. 

Under  the  influence  of  cancer  development  there  may  be  at  times — 
though  rarely — an  Addison-like  pigmentation  (8,  81),.  but  exposure  to 
the  sun's  rays  may  also  be  a  favoring  factor.  It  is  possible  that  nutri- 
tive or  toxemic  disturbances  of  the  sympathetic  nervous  system  play  a 
part  in  this  connection,  since  melanosis  of  the  skin  occurs  with  processes 
that  are  accompanied  by  cachexia,  such  as  cancer  of  the  pancreas,  peri- 
toneal tuberculosis,  etc. 

Whoever  believes  that  constitutional  factors  predispose  to  cancerous 
disease  will  not  be  heedless  of  congenital  pigmentary  anomalies. 

Thus  in  Case  89  the  trunk  showed  depigmented  zones  arranged  in 
girdle  fashion,  which  is  occasionally  observal)le  in  pernicious  anemias. 

Night-sweats  sometimes  count  among  the  early  symptoms  of  gastric 
cancer  and  might  lead  one  to  the  wrong  diagnosis  of  tuberculosis   (88). 

Motor  Apparatus 

The  occurrence  of  hallux  valgus  (3,  IT,  63)  and  Heberden's  nodes 
(75,  78)  as  constitutional  marks,  as  well  as  the  anamnestic  determina- 
tion of  arthritic  antecedents,  are  to  be  considered  worthy  of  attention. 


FECES  AND  STOMACH  CONTENTS 

The  examination  of  stomach  contents  and  feces  is  not  a  condition 
sine  qua  non  for  tlie  diagnosis  of  gastric  cancer;  moreover,  the  cases 
are  not  rare  in  which  the  chemical  and  microscopical  examinations  are 
ornamental  rather  than  practical,  of  complementary  rather  than  funda- 
mental significance.  Naturally  this  is  especially  true  in  advanced  stages 
of  the  disease  when  a  distinct  tumor  can  be  felt. 

If,  for  didactic  reasons  or  for  the  sake  of  the  greatest  possible  cer- 
tainty, a  microscopic  or  chemical  finding  is  desirable,  it  will  be  well  to 
examine  the  feces  in  the  first  place.-  The  principle  that  such  methods 
of  examination  should  be  employed  first  as  are  most  sparing  to  the  patient 
ought  to  gain  more  recognition.  Lavage  of  the  stomach,  when  ulcera- 
tion and  disintegration  is  going  on,  is  not  an  indifferent  matter,  and 
includes  the  danger  of  hemorrhage,  even  of  perforation.  This,  however, 
should  not  deter  one  from  performing  lavage  when  it  is  necessary  for 
diagnosis ;   statistically   the  danger   of  complications   is   slight. 

But  even  in  these  cases  I  would  recommend  that  the  feces  be  exam- 
ined first.  There  are  three  questions  for  which  an  answer  must  be  found 
in  the  chemical  and  microscopic  investigation  of  feces  or  stomach  con- 
tents : 


CANCER    OF    THE    STOMACH  91 

1.  Is  there  hemorrhage  of  the  stomach? 

2.  Is  there  stagnation   of  stomach  contents? 

3.  In  what  state  are  the  secretions  of  the  gastric  mucosa? 

(Janlfic  HemorrJiage 

Gushing  hemorrhages  with  elimination  per  os  or  per  anum  are,  gen- 
erally speaking,  foreign  to  the  clinical  picture  of  gastric  cancer,  although 
such  ulcerous  Ijchavior  may  occasionally  mark  the  beginning  or  end  of 
the  process.  It  is  well  known  that  those  small  hemorrhages  which  lead 
to  coifee-ground  vomiting  are  incomparably  more  frequent.  To  a  cer- 
tain extent  they  may  come  from  a  gastric  mucosa  that  has  not  under- 
gone carcinomatous  alteration,  but  is  in  a  state  of  active  or  passive 
h^'peremia. 

Analogous  coffee-ground  vomiting  is  sometimes  fqund  without  ulcer- 
ation in  the  terminal  stages  of  pneumonia,  diabetes,  sepsis,  icterus  gravis; 
furthermore,  in  gastric  crises  and  intestinal  stenoses.  These  quantita- 
tiveW  slight  gastric  hemorrhages,  which  are  the  rule  in  cancer  of  the 
stomach,  do  not  give  rise  to  characteristic  tar-colored  stools ;  they  re- 
main macroscopically  "'occult,"  but  are  chemically  demonstrable.  It  has 
already  been  stated  elsewhere  (page  14)  that  these  "chemical  bleedings" 
in  the  feces  have  great  significance,  even  for  the  early  diagnosis  of  gas- 
tric cancer. 

Is  a  positive  chemical  blood  finding  in  the  feces  a  constant,  regular 
accompaniment  of  gastric  cancer? 

This  question,  which  is  of  great  diagnostic  import,  I  would  like  to 
answer  conditionally  only,  namely,  on  the  supposition  that  my  technique 
of  examination  for  blood-coloring  material  be  used.  The  same  is,  as  has 
been  previously  stated,  designedly  coarse.  By  the  use  of  large  quantities 
of  feces  and  very  thorough  extraction,  positive  results  may  certainly  be 
obtained  in  cases  where  by  the  use  of  my  very  much  simplified  technique, 
which  I  have  reconmiended  for  practical  diagnostic  purposes,  a  negative 
finding  is  the  result.  As  emphasized  on  a  former  page,  the  diagnostician, 
in  contradistinction  to  the  professional  chemist,  is  interested  in  chemical , 
substances — in  this  case  blood-coloring  material — not  for  their  own  sake, 
but  because  of  their  diagnostic  value,  i.e.,  their  presence  in  certain  pro- 
portions. 

The  above  question  may  be  answered  by  saying  that,  especially  with 
a  palpable  tumor,  the  demonstration  of  blood  is  constantly  successful 
and  only  exceptionally  negative.  Furthermore,  I  would  not  look  upon  a 
negative  result  as  being  opposed  to  the  diagnosis  of  gastric  cancer,  pro- 
viding such  negative  findings  be  not  absent  for  weeks  at  a  time. 

Positive  findings  will  have  to  be  utilized  with  much  greater  precau- 
tions if  they  are  obtained  with  more  sensitive  tests. 

Symptoms   of    Gastric   Stagnation 
in    the   Feces 

Since  in  many  cases  impaired  motor  function  of  the  stomach  figures 
among  early  symptoms  of  gastric  cancer,  we  have  already  discussed  on 


92  TUMORS    OF    THE    ABDOMINAL    VISCERA 

a  former  page  those  symptoms  of  the  disease  which  are  referable  to  ob- 
struction of  the  pyloric  passage  and  stagnation  of  the  stomach,  namely, 
such  manifestations  as  visible  gastric  peristalsis,  balloon-stomach,  SH2 
fermentation,  colic  of  pyloric  stenosis,  etc. 

The  history  (vomiting  foods  of  the  previous  day)  also  will  some- 
times lead  to  the  assumption  of  gastric  stagnation.  We  can  also  infer 
the  presence  of  gastric  stagnation  from  examination  of  the  feces,  partic- 
ularly with  reference  to  vegetations.^* 

Probable  and  almost  certain  evidence  of  stagnation  can  be  inferred 
from  the  presence  of  stomach  sarcince,  which  from  man}'^  years'  experience 
along  these  lines  I  consider  a  separate  species.^^ 

Sarcinfe  in  the  feces  are  always  of  gastric  origin  and  equivalent  to 
the  demonstration  of  sarcinje  in  the  stomach  itself. 

But  sarcinse  develop  in  the  stomach  only  when  there  is  present  stag- 
nation of  high  degree ;  their  constant  presence  during  continued  observa- 
tions almost  always  coincides  with  the  existence  of  organic  stenosis  at 
the  pylorus  or  duodenum. 

There  seems  to  be  some  relation  between  the  formation  of  SH2  and 
the  presence  of  sarcinjE. 

Malignant  pyloric  stenoses  are  accompanied  by  sarcince  vegetation, 
especially  so  long  as  the  HCl  secretion  persists. 

The  persistent  finding  of  sarcinas  in  the  feces  almost  always  is  jus- 
tification for  assuming  gastric  stagnation  of  high  degree  which  is  de- 
pendent on  pyloric  stenosis. 

The  assumption  of  rather  intense  stagnation  of  stomach  contents  is 
also  close  at  hand  in  those  cases  where  the  lactic-acid  bacilli  are  promi- 
nent in  the  feces. 

Extreme  cases  of  this  kind,  in  which  the  colon  bacillus  is  forced  into 
tlic  background,  are  usually  cases  of  cancer  of  the  pylorus.  Here  the 
changed  appearance  of  the  bacteriological  picture  of  the  stool  is  due  to 
the  transition  of  abundant  lactic-acid  bacilli  from  the  stomach  into  the 
bowel.  At  the  "Naturforscher"  Congress  in  Meran  in  1906,  I  had  occa- 
sion to  point  out  the  fact  that  under  pathological  conditions  even  the 
small  intestine  could  become  the  brooding-place  for  lactic-acid  bacilli, 
so  that  with  diseased  conditions  of  the  same — which,  however,  are  rare — 
there  may  be  an  abundant  vegetation  of  lactic-acid  bacilli  in  the  feces. 

A  finding  having  such  a  genesis  I  observed  in  a  case  of  lympho- 
sarcoma of  the  small  intestine  and  in  a  case  of  chronic,  deep-seated  and 
severe  stenosis  of  the  small  gut. 

These  cases  are  very  rare  exceptions  to  the  general  rule,  that  an 
abundant  vegetation  of  lactic-acid  bacilli  in  the  feces  points  in  the  first 
place  to  the  stomach  as  their  source,  and  in  general  coincides  with  the 
finding  of  cancer  of  the  pylorus. 

Besides   the  ulcerative  process,  stagnation   and  deficiency   of  hj^dro- 

'^  See  page  20. 

'"See  R.  Schmidt,  Med.  Klinik,  1909,  No.  2.  Mitt.  d.  Ges.  f.  innere  Med..  Vienna, 
III,  page  240.  Mitt,  aus  den  Grenzgebieten  der  Med.  und  Chirurgie,  Vol.  XV.  5.H., 
1906. 


CANCER    OF    THE    STOMACH  93 

chloric  acid  are  the  two  fundamental  causes  for  the  development  of  lactic- 
acid  bacilli  in  the  stomach,  and  the  numerical  strength  of  the  lactic-acid 
bacilli  that  arrive  at  development  is  mostly  in  direct  proportion  to  the 
quantitative  extent  of  both  these  factors. 

This  determines  the  diagnostic  value.  Lactic-acid  bacilli,  appearing 
sporadically,  are  of  no  value  for  diagnosis ;  it  is  only  their  grouping  in 
a  "vegetation  picture"  that  renders  them  diagnostically  valuable.  The 
correct  estimate  of  this  numerical  strength  will  of  course  depend  upon 
personal  experience.  Whoever  is  not  in  a  position  to  avail  himself  of 
the  latter,  will  do  better,  in  the  beginning  of  his  observations,  not  to 
include  in  his  diagnostic  considerations  the  gastro-intestinal  bacterio- 
logical findings,  since  mistakes  may  result  only  all  too  easily. 

It  would  also  be  a  great  mistake  to  rule  out  a  gastric  cancer  because 
of  the  absence  of  lactic-acid  bacilli. 

State  of  Secretions 

Since  the  time  of  V.  Velden,  in  1879,  the  absence  of  HCl  in  gastric 
cancer  passed  as  a  sort  of  axiom. 

How^ever,  cases  of  gastric  cancer  are  not  rare  in  which,  even  in  ad- 
vanced stages  of  the  disease,  there  is  persistence  of  HCl  secretion.'**^  The 
mucous  membrane  of  the  cancerous  stomach  seems  to  respond  for  a  long 
time  with  HCl  secretion,  especially  to  the  severe  irritation  produced  by 
the  products  of  decomposing  stomach  contents  obtained  in  the  morning 
from  a  fasting  stomach. 

After  lavage  of  the  stomach,  how^ever,  the  mild  irritation  of  a  tea 
and  roll  breakfast  is  not  sufficient  to  stimulate  HCl  secretion  anew. 

Occasional,  persistence  of  HCl  secretion,  despite  far-advanced  car- 
cinoma of  the  stomach,  proves  that  there  can  be  no  direct  connection  be- 
tween cancer  of  the  stomach  and  achlorhydria.  A  causative  link  is 
necessary,  and  it  would  seem  like  forcing  things  w^ere  we  to  look  for  this 
link  elsewhere  than  in  the  chronic  gastritis  that  accompanies  the  devel- 
opment of  cancer. 

In  this  way  we  can  also  explain  those  cases  in  which  achlorhydria 
continues  after  resection  of  the  stomach. "^^ 

At  times,  of  course,  even  factors  of  dyscrasia  may  have  an  influence 
on  the  state  of  secretions  of  the  gastric  mucosa. 

Persistence  of  HCl  secretion  is  also  met  with  in  cases  in  which  there 
is  no  ground  whatever  for  svipposing  a  pre-existing  ulcer.  There  would 
be  really  no  reason  why  a  cancer  having  an  ulcer  for  its  base  should  act 
differently  in  this  respect.  In  general,  the  conditions  for  persistence  of 
HCl  seem  to  be  especially  favorable  if  the  cancer  is  limited  locally,  ex- 
tending in  depth  rather  than  along  the  surface. 

A  positive  finding  of  HCl,  therefore,  especially  when  occurring  in 
medium  or  even  subnormal  quantities,  must  not  deter  us  from  the  diag- 
nosis of  gastric  cancer,  providing  there  are  other  sufficient  grounds  for 

*°Nos.  13,  22,  48,  56,  66,  67,  72,  76,  79,  80. 

*^H.  Mafti,  Deiitsche  Zeitschr.  f.  Chiriirgie,  Vol.  77  (107  Falle  von  Magenreaktion). 


94  TUMORS    OF    THE    ABDOMINAL    VISCERA 

it  clinically.    More  important  than  a  single  finding  will  be  the  determina- 
tion of  the  HCl  curve,  which  at  times  declines  rapidly  (52). 

Chemical  Analysis  of  Stomach 
Contents 

In  determining  the  secretory  conditions,  the  analysis  of  stomach  con- 
tents will  always  be  of  prime  importance. 

If  vomited  stomach  contents  are  not  available,  or  examination  of 
same  has  not  already  yielded  more  or  less  decisive  findings,  such  as  stag- 
nating food  remains  of  the  previous  day,  areas  of  lactic-acid  bacilli,  etc., 
it  will  be  advisable  to  wash  out  the  stomach  after  a  test  breakfast  of 
water  and  a  roll  (about  400  cm^  of  unsweetened  tea,  or  water,  and  one 
roll).     Withdrawal  to  take  place  about  %  "^  ^^^  hour  after  taking, 

RiegeVs  test  dinner  had  better  be  avoided  on  account  of  the  fre- 
quently existing  intolerance  for  meat,  and  it  offers  no  other  advantages. 

The  evening  before  the  test  breakfast  the  patient  should  eat  prunes 
or  some  ham,  so  that  in  case  of  pronounced  motor  insufficiency  plant- 
cells  or  muscle  fibres  may  show  up  in  the  withdrawn  test  breakfast. 

For  qualitative  as  well  as  quantitative  purposes,  we  would  recom- 
mend Toepfer's  HCl  reagent,^-  i.e.,  a  57f  alcoholic  solution  of  dimethyla- 
midoazobenzol.  By  blotting  the  stopper  of  the  reagent  bottle  on  a  small 
folded  filter-paper  there  results  a  yellow  circular  disk.  Dip  the  end  of 
a  glass  rod  into  the  test  breakfast  that  has  been  withdrawn  and  streak 
over  half  the  yellow  disk.  If  the  color  remains  yellow,  or  becomes  light 
red,  it  indicates  that  free  HCl  is  absent  or  is  present  only  in  minimal 
quantities. 

The  total  acidity  is  estimated  in  the  well-known  way  by  means  of  a 
1%  alcoholic  phenolphtiialein  solution  and  /4()  •  .  .Na  OH. 

Further  determinations,  such  as  combined  HCl,  organic  acids,  pepsin, 
active  principles  of  glands,  steapsin,  have  no  decisive  diagnostic  sig- 
nificance. 

The  same  is  true  of  lactic-acid  tests  still  so  much  in  vogue.  With- 
out stagnation  there  is  no  formation  of  lactic  acid  in  the  stomach.  If, 
as  is  prescribed  in  cases  of  stagnation,  the  stomach  is  thoroughly  washed 
out  before  giving  the  test  breakfast,  and  then  the  test  breakfast  is  given, 
Uffelmann's  test  will  prove  negative  even  in  cases  of  advanced  gastric  can- 
cer, providing  no  contents  remained  in  the  stomach  after  lavage.  The 
excitants  of  lactic-acid  formation  in  the  stomach — among  which  strains 
of  colon  bacilli  certainly  also  play  a  part — are  simply  not  able  to  gen- 
erate sufficient  quantities  of  lactic  acid  from  the  carbohydrates  of  the 
test  breakfast  in  the  short  space  of  %  of  an  hour.^^ 

The  demonstration  of  lactic  acid,  which  attains  the  highest  value 
when  occurring  in  stagnating  stomach  contents,  is  nothing  more  than  a 
chemically  demonstrable  partial  evidence  'of  stagnation  in  case  of  de- 
ficient HCl  secretion ;  but  stagnation  is  frequently  indicated  macroscopi- 

^^M.   Toepfer,  Zeitschr.   f.  physiol.  Chemie,   1894,  Vol.   19,  page  104. 
*^  Boas,   Uber   das    Vorkomnien    und    die    diagnostische    Bedeiitung   der    Milchsjiure 
im   Mageninhalt.   '  Miinchener  nied.   Wochenschr.,   1893,  No.   43. 


CANCER    OF    THE    STOMACH  95 

cally,  especially  also  microscopically,  by  the  absence  in  the  test  break- 
fast of  food  remains,  such  as  muscle  fibres,  plant  tissues,  etc.,  **  and  also 
finds  particular  microscopical  expression  in  the  colonization  of  vegetable 
and  animal  parasites.^'' 

Microscopical  Examination  of 
Stomach    Contents 

Order  of  microscopical  examination  of  vomited  or  withdrawn  stom- 
ach contents:  One  loopful  of  stomach  content  is  placed  upon  a  slide 
together  with  one  drop  of  alcoholic  solution  of  Sudan  HI,  then  thor- 
oughly mixed  with  one  drop  of  Lugol's  solution.  One  loopful  of  this 
mixture  is  taken  for  examination. 

In  examining  same  the  following  3  groups  of  findings  must  be  con- 
sidered, similar  to  those  in  fecal  examinations: 

/.    Alimentary  findings: 

a.  Muscle  fibres ;  after  test  breakfast  these  are  a  certain  proof  of 
great  stagnation.  The  Lugol  solution  has  colored  them  yellowish-brown 
or  green  (presence  of  bilirubin). 

b.  Starch  granules,  stained  blue  with  Lugol  solution.  Normal  find- 
ing after  a  test  breakfast. 

c.  Neutral  fat  and  soap  needles.  The  neutral  fat  is  stained  red  with 
Sudan  III ;  the  soap  needles  are  unstained.  These  and  fatt}^  acid  needles 
must  not  be  confused  with  the  "long"  bacillus.  After  a  test  breakfast 
these  findings  are  signs  of  stagnation,  providing  the  patient  has  not 
taken  any  milk  before  it. 

d.  Plant  tissues,  coming  from  currants,  cranberries,  prunes,  etc., 
eaten  the  evening  before  and  found  in  the  test  breakfast,  are  always  a 
sign  of  stagnation. 

//.  Anatomical  findings,  depending  upon  anatomical  alterations  of 
the  gastric  mucosa : 

a.  Evidence  of  hemorrhage,  as  shown  by  erythrocyte  shadows  ^''  or 
granules  of  brown-colored  blood  pigment  detritus,  in  which  the  nuclei  of 
leucocytes  are  most  often  visible. 

b.  Pus.  Found  mostly  in  far-advanced  and  much  ulcerating  cancers, 
and  then  only  seldom. 

c.  Admixtures  of  mucus  (best  studied  macroscopically). 

d.  Tumor  particles. ^'^  The  appearance  of  the  latter  probably  al- 
ways denotes  an  advanced  stage  of  the  disease  and  is  not  a  frequent  find- 
ing. In  order  to  avoid  mistaking  these  for  shreds  of  normal  nmcous 
membrane  an  exact  histological  examination  is  required. 

**  For  this  reason  it  is  advisable  to  give  the  patient  currants,  cranberries,  prunes, 
etc.,  the  evening  before  the  test  breakfast. 

*-^  Coni]iare  Gastro-intestinal  GroMths,  page  20. 

^"  This  finding  indicates  that  the  hemorrhage  is  not  of  recent  date,  at  least  has  not 
occurred  during  the  withdrawal  of  the  food. 

*'  See  Reineboth,  Deutsches  Arch.  f.  klin.  Med.,  1897,  Vol.  58,  page  6-2. 


96  TUMORS    OF    THE    ABDOMINAL    VISCERA 

///.    Bacterial  ^^  and  vegetable  growths. 

a.  Lactic-acid  bacilli  not  stained  by  Lugol  solution. 

b.  Leptothrix  forms ;  long,  but  plump  rod-shapes  and  mostly  stained 
violet  blue  by  Lugol. 

c.  Forms  of  colon  bacilli. 

d.  "Stomach"  sarcina- ;  the  large-celled  type  staining  yellowish  brown 
with  Lugol,  the  small-celled  type  remaining  unstained. 

e.  Yeast-cells ;  when  pathologically  increased  these  are  sometimes 
stained  dark  brown  (glycogen  reaction.''). 

/.  Mycelium  threads  of  mould  fungi. 
g.   Megastoma  entericum. 

Signs  of  HypoclilorJiydria  in 
the  Feces 

As  far  as  the  determination  of  deficient  HCl  in  the  gastric  juice  is 
concerned,  certain  probable  conclusions  may  also  be  drawn  from  exami- 
nation of  the  feces. 

Alimentary  findings  would  come  into  consideration  in  so  far  as  we 
are  dealing  with  remnants  of  muscle  fibres.  Yet  in  the  using  up  of  food- 
stuffs there  are  different  factors  that  must  be  taken  into  consideration, 
such  as  quality  of  the  meat  food,  its  manner  of  connninution ;  gastric  and 
intestinal  juice,  pancreatic  secretion,  motility  of  the  gastro-intestinal 
tract,  etc.  This  multiplicity  of  influential  factors  renders  the  interpreta- 
tion of  alimentary  findings  in  the  feces  more  or  less  illusory  and  there- 
fore would  make  it  appear  needless  to  carry  out  a  test  diet,  which  for 
that  matter  would  be  impracticable  in  view  of  the  much  limited  food 
tolerance  in  connection  with  gastric  cancer.  In  cases  where  with  fairly 
regular  bowel  movements  and  without  any  particular  bowel  atony  and 
moderate  intake  of  meat  (once  a  day)  there  are  more  or  less  abundant 
muscle  fibres  whose  transverse  stria?  are  well  preserved  in  the  feces,  it 
will  generally  be  permissible  to  assume  a  diminished  hydrochloric-acid 
secretion. 

I  consider  the  experiment  of  Sahli,  i.e.,  digestion  of  catgut  {SaldVs 
desmoidrcaction)^"  of  diagnostic  value  in  those  cases  where  it  proves 
negative,  i.e.,  where  the  urine  does  not  become  colored.  In  these  cases 
HCl  is  always  diminished  or  entirely  absent. 

It  is  advisable  to  carry  out  the  test  in  the  following  way :  One  half 
hour  after  taking  the  breakfast,  consisting  of  tea  and  a  roll,  the  patient 
swallows  a  little  sack  made  of  India-rubber,  which  contains  the  reagent 
and  is  tied  up  with  very  fine  raw  catgut;  the  contents  is  a  methylene  pill 
(.05  medicinal  methylene  blue  together  with  extr.  and  powder  liquir. 
aa  .04).^<^ 

My  own  experience  has  convinced  me  that  permanent  absence  of  blue 

**  Especial  regard  should  lie  had  for  vomited  material  and  also  the  sediment  of 
the  irrigation   fluid. 

«  7?_  Fravenheryer,  Sahli's  Desmoidreaktion,  etc.     Wiener  med.  Woch.,  1907,  No.  30. 
M  Pi-epared  by  the  firm  of  G.  Pohl  in  Schonbaum,  District  of  Danzig. 


CANCER    OF    THE    STOMACH  97 

discoloration  of  the  urine  always  justifies  us  in  assuming  at  least  a  hypo- 
chlorh^'dria ;  frequently  we  are  dealing  with  achlorhydria. 

Positive  findings  (blue  discoloration  of  the  urine  after  several  hours) 
I  do  not  consider  of  value,  as  among  other  things  such  accidents  as  im- 
perfect tying  of  the  sack,  etc.,  may  cause  the  India-rubber  sack  to  open. 

The  abundant  occurrence  of  lactic-acid  bacilli  in  the  feces  is,  as  has 
previously  been  stated,  a  finding  which  in  most  cases  is  concomitant  with 
achlorhydria. 

Another  finding  in  the  feces  which  I  consider  highly  suspicious  of 
achlorhydria  or  subacidit}',  is  the  presence  of  animal  parasites,  such  as 
megastoma  entericum  (4),  tjenia,  ascarides,  etc.  In  this  connection  it 
seems  to  me  that  the  subacidity  is  not  the  result  but  the  cause  of  mod- 
erate parasitic  invasion.  In  most  instances,  for  that  matter,  we  are  here 
concerned  with  chronic  forms  of  subacidity,  such  as  achylia  gastrica. 


TYPES    OF   DISEASE,    COURSE    AND    DURATION 

Despite  the  biological  and  anatomical  similarity  of  the  underlying 
condition,  the  clinical  pictures  afforded  by  cancerous  disease  of  the  stom- 
ach-wall vary  within  wude  limits,  and  individual  types  can  easily  be 
recognized. 

Mummifying   Type 

Thus  there  is  a  "mummifying"  type,  observed  most  frequently  in 
advanced  age,  especially  if  the  carcinoma  be  of  a  fibrous  character  and 
encircles  the  pylorus.  In  these  cases  edemas  almost  never  occur.  As  a 
result  of  continued  losses  of  fluids  through  massive  evacuation  of  the 
highly  elastic  stomach  there  ensues  severe  exsiccation  of  the  tissues.  The 
vomiting  is  mostly  "coffee-ground,"  containing  abundant  lactic-acid  ba- 
cilli.    The  heart  is  small,  with  now  and  then  bradycardia. 

Hydropic- Anemic  Forms 

The  very  opposite  to  the  above  is  the  hydropic-anemic  form,^^  which 
is  frequently  found  at  a  less  mature  age,  being  characterized  by  the 
development  of  a  general  dropsy  of  the  skin,  besides  effusions  into  the 
serous  cavities.  These  are  mostly  medullary,  severely  ulcerating  and 
constantly  bleeding,  extensive  tumor-masses  which  produce  little  or  no 
stenosis. 

Not  infrequently  the  stomach  contents  contain  lactic-acid  bacilli  in 
only  moderate  quantity,  vomiting  is  rare,  and  appetite  and  tolerance  of 
the  stomach  are  often  very  good.  The  heart  is  dilated,  there  are  present 
anemic  murmurs  and  venous  hums,  tachycardia. 

Anemic    Type 

In  the  early  stages  of  this  form  anemia  sets  in  without  anasarca  or 
dropsies,  so  that  this  "anemic"  tj'pe  in  its  external  aspect  reminds  one 

"  Nos.  23,  41. 


98  TUMORS    OF    THE    ABDOMINAL    VISCERA 

chiefly  of  the  picture  of  pernicious  anemias.  The  color  of  the  face  inclines 
to  yellow,  which  may  be  dependent  upon  hemochromatosis;  even  Add'uon- 
like  pigmentations  may  occur  with  this  form. 

Peritoneal  and  Pleural  Forms 

Finally,  I  would  like  to  designate  as  "peritoneal-pleural"  forms  those 
cases  in  which  peritoneal  or  pleural  metastasis  occurs  early,  thus  in  most 
instances  leading  to  hemorrhagic  or  "milky,"  turbid  ascites.  Edemas  of 
the  skin  are  not  characteristic  of  this  form. 

This  type  is  led  up  to  especially  by  scirrhus  carcinomas  which  dif- 
fusely infiltrate  the  stomach  and  lead  to  its  contraction."-  Vomiting  or 
eructation  of  gases  is  very  prominent,  the  vomiting  is  not  copious,  but 
in  conformance  with  the  small  lumen  of  the  stomach  occurs  in  small  quan- 
tities. 

This  form  can  easily  be  mistaken  for  tubercular  serositis,  because 
by  way  of  the  lymphatic  current  it  leads  to  metastases  of  the  serous  sur- 
faces, omentum,  ligamentum  teres,  and  often  also  the  umbilicus :  ^'"^  the 
liver,  as  a  rule,  remains  free  from  the  more  extensive  metastases. 

The  classification  of  the  four  types  just  discussed  was  the  result  of 
general  impressions  gained  by  inspection. 

Various  other  types  could  be  singled  out,  based  on  prominent  detailed 
symptoms,  so  that  we  might  speak  of  "rectal,"  "gynecological"  and  other 
types  of  gastric  cancer. 

Such  classification,  however,  seems  to  me  more  or  less  artificial  and 
arbitrary.  The  facts  concerning  same  will  be  discussed  in  the  chapter 
on  "Differential  Diagnosis." 


Course  of  the  Disease 

With  regard  to  the  course  of  the  disease  it  seems  to  me  particularly 
worthy  of  note  that  the  disease  curve  is  not  a  progressively  increasing 
one,  but  frequently  shows  remissions,  which  are  partly  spontaneous  and 
partly  the  result  of  treatment. 

It  will  have  to  be  borne  in  mind  that  the  complaints  of  the  patients 
are  not  referable  directly  to  the  tumor  itself  but  rather  are  due  to  chronic 
gastritis,  stenosis  of  the  pylorus,  hemorrhages,  etc.  The  stenosis  may 
be  diminished  through  ulceration  or  it  may  be  overcome  by  compensatory 
hypertrophy  of  the  musculature  of  the  stomach.  Chronic  gastritis  is 
amenable  to  therapeutic  influences,  the  hemorrhages  may  cease,  etc. 
Nothing  would  be  more  erroneous  than  to  allow  such  deceitful  improve- 
ments to  throw  one  off  the  track  to  the  right  diagnosis. 

Even  the  Karlsbad  cures,  which  ordinarily  rather  increase  the  com- 
plaints of  gastric  cancer  patients,  are  sometimes  accompanied  by  good 
results  (65,  79).  The  stomach  complaint  may  even  disappear  sponta- 
neously for  a  long  time   (8,  31,  44).      Existing  pains  may  become  less 

"  Nos.  2,  6,  12,  53,  60,  70,  81. 

"  See,  Qti^nu  et  Longuel,  Du  cancer  secondaire  de  ronibilic.  Revue  de  Chirurgie, 
1896,  XVI,  page  96. 


CANCER    OF    THE    STOMACH  99 

or  vanish  entirely;  in  tliese  latter  cases  the  cessation  of  HCl  secretion 
and  the  diminished  food  intake  are  the  determining  factors. 

In  this  way  the  body-weight  may,  even  without  the  occurrence  of 
edema,  be  considerably  increased  shortly  before  death  (58). 

After  operative  interference,  even  when  there  remain  behind  cancerous 
tumor-masses,  the  body-weight  may  undergo  a  temporary  increase  (59). 

Duration 

The  duration  of  the  disease  manifestations  from  their  first  appearance 
to  their  ending  by  death  naturally  varies  within  wide  limits.'"'^  Only  in 
a  single  case  (66)  of  my  histories  is  there  a  probability  of  3  years'  dura- 
tion. Not  infrequently  cases  are  found  that  extend  over  2  years  and 
several  months.  In  many  cases,  of  course,  the  first  symptoms  of  the 
disease  as  shown  by  ananmesis  date  back  only  a  few  months  prior  to  death. 

However,  cases  that  run  over  a  period  of  two  years  are  not  rare,  and 
they  are  the  cases  in  which  on  retrospection  one  can  say :  it  would  have 
been  possible  to  make  the  diagnosis  at  the  beginning  of  the  disease.  Pes- 
simism with  regard  to  the  possibility  of  an  early  diagnosis,  therefore, 
seems  to  me  out  of  place.  Of  course,  there  are  cases  having  an  apparently 
long  period  of  latency. 

Period  of  Latency 

But  the  period  of  latency  can  be  influenced,  and  I  hope  that  also  the 
present  work  will  contribute  to  its  abbreviation  in  this  or  that  case. 
A  physician  who  is  well  instructed  in  the  symptomatology  of  cancer  dis- 
eases will  not  seldom  find  suspicious  factors  of  malignant  disease  in  those 
cases  which,  as  far  as  the  less  experienced  observer  is  concerned,  are  still 
in  their  "latent  period." 

On  the  other  hand,  it  is  the  duty  of  physicians  to  make  clear  to 
their  patients  that  stomach  complaints  of  milder  degree,  especially  when 
occurring  in  individuals  with  otherwise  strong  digestive  organs,  should 
never  be  underestimated. 

I  am  also  convinced  that  continued  clinical  study  of  the  cancer 
problem  will  bring  to  light  a  decided  disposition  on  the  part  of  certain 
individuals  to  cancerous  disease  and  will  also  yield  the  details  *by  which 
to  recognize  it. 

What  we  are  accustomed  to  designate  as  period  of  latency  is  certainly 
not  a  time  during  which  there  are  no  symptoms,  but  rather  a  time  dur- 
ing which,  either  through  the  fault  of  the  patient  or  his  medical  adviser, 
the  existing  symptoms  are  not  observed ;  this  can  and  will  be  changed. 


SUSPICIOUS   FACTORS    AND   DIFFERENTIAL    DIAGNOSIS 

That  a  tumor  in  the  epigastrium  plus  stomach  contents  deficient  in 
free  HCl  but  richly  laden  with  lactic-acid  bacilli,  arouses  the  suspicion 
of  gastric  cancer,  needs  no  special  mention. 

'^  See  Case  History,  ad  9. 


100  TUMORS    OF    THE    ABDOMINAL    VISCERA 

We  have  already  discussed  in  detail  the  suspicious  factors  in  so  far 
as  they  form  a  part  of  the  symptomatology.  The  diagnosis  will  result 
from  the  correct  grouping  of  all  the  symptoms  in  a  given  case. 

Here  it  may  be  permissible  to  call  attention  to  several  brief,  rather 
general  considerations  and  combinations  of  ideas  which  may  give  rise  to 
the  suspicion  of  cancerous  disease  of  the  stomach,  even  in  its  incipiency. 

Such  suspicious  factors  would  be  among  others : 

1.  Unaccountable  occurrence  after  the  30th  year  of  gastric  s^^mp- 
toms,  such  as  pressure  in  the  stomach,  eructation,  etc.,  in  an  individual 
previously  favored  with  a  healthy  gastro-intestinal  tract  ("gastro-intes- 
tinal  athletes"). 

2.  Given  the  same  gastro-intestinal  individuality,  a  disproportion  be- 
tween cause  and  effect  in  so  far  as  the  accused  dietetic  error  gives  rise 
to  strikingly  stubborn  stomach  complaints. 

3.  Rapid  diminution  of  gastric  tolerance  in  a  "stomach  athlete,"  e.g., 
when  soon  only  milk  and  soup  are  well  borne. 

4.  Long  duration  of  occult  intestinal  hemorrhage  in  suspected  ulcer 
despite  proper  treatment  with  prolonged  rest  in  bed. 

5.  As  certain  forms  of  gastric  cancer  begin  and  continue  with  the 
typical  subjective  symptoms  of  peptic  ulcer,  and  as  the  treatment  of 
ulcer  will  also  produce  apparent  cures  in  these  cases,  it  will  always  be 
advisable  to  make  the  diagnosis  of  gastric  ulcer  with  reservation. 

Personally  I  consider  this  reservation  especially  appropriate  in  cases 
where  we  are  dealing  with  strong  ''"'  individuals  previously  enjoying  good 
digestive  energy,  between  the  ages  of  40  and  50.  Such  patients  should 
be  warned  of  the  possibility  of  a  malignant  ulceration,  so  that  they  place 
themselves  under  continued  observation. 

6.  Finding  of  sarcinae  in  the  stomach  contents  or  feces  when  the 
stomach  ailments  are  of  short  duration,  denoting  a  rapid  development  of 
pyloric  stenosis. ^^ 

7.  Stubborn  obstipation  in  an  individual  who  has  hitherto  been  reg- 
ular.^'^ 


Differential  Diagnosis 

The  foregoing  and  similar  associations  of  ideas  will  frequently  awaken 
the  suspicion  of  carcinomatous  disease  of  the  stomach  and  give  occasion 
for  further  differential  diagnostic  considerations. 

As  a  measure  of  prime  importance  in  differential  diagnosis  I  regard 
repeated  examinations  of  the  feces  for  "occult"  hemorrhages.^^  If  the 
findings  prove  constantly  negative,  a  gastric  cancer  is  highly  improbable. 

^^  Simple  gastric  ulcer  seems  generally  to  be  more  common  in  weak  individuals  with 
phthisical  appearance,  irritable  vaso-niotor  weakness  and  enteroptosis.  See  Mitt.  d. 
Ges.  f.  innere  Med.  u.  Kinderheilk.,  1910,  page  87. 

''"Nos.  16,  22,  35,  52,  56,  72. 

"Nos.  37,  39,  40,  42,  91. 

^^  See  page  16. 


CANCER    OF    THE    STOMACH  101 

Chronic  Gastriiis 

Pr()l);ihly  one  of  tlio  most  frequent  erroneous  diaf^noses  is  "chronic 
gastric  catarrh."  This  diagnosis  seems  to  be  made  as  extremely  frequent 
as  it  is  extremely  seldom  justified,  for  "chronic  gastritis"  is  much  more 
of  an  anatomical  than  a  clinical  conception.  The  severest  "chronic  gas- 
tritis" may  he  observed  post  mortem,  whereas  during  life  there  were 
only  extremely  mild  or  not  any  gastric  symptoms.  This  contrast  is  fa- 
miliar to  anybody  who  has  witnessed  many  autopsies,  I  do  not  think  that 
during  the  course  of  an  entire  year  I  have  had  a  single  occasion  among 
my  patients  to  diagnose  "chronic  gastritis"  as  the  sole  cause  of  existing 
gastric  complaints. 

In  cases  where  pains  become  prominent,  where  they  are  mechanically 
influenced  by  position,  etc.,  in  short  where  there  exist  rather  serious  di- 
gestive difficulties,  this  diagnosis  of  "chronic  gastritis"  must  be  made 
cautiousl3^  It  is  the  greatest  enemy  to  the  early  diagnosis  of  gastric 
cancer. 

Gastric  Ulcer 

As  long  as  there  is  no  distinct  tumor  at  hand,*^^  confusion  with  a 
benign  ulceration  of  the  stomach  is  not  only  conceivable  but  at  times 
unavoidable. 

Common  to  both  above  all  else  is  the  demonstration  of  blood  in  the 
feces. 

To  my  mind  the  only  reliable  criterion  is  the  course  of  the  disease 
and  the  therapeutic  test ;  but  even  here  great  caution  should  be  exercised, 
since  the  subjective  complaints  of  carcinoma  also  may  often  be  favorably 
influenced  by  the  gastric  ulcer  treatment,  especially  with  rest  in  bed. 
The  rapid  occurrence  of  severe  stagnation,  persistence  of  "occult  melena," 
despite  a  rest  cure  of  many  weeks,  may  decide  in  favor  of  malignancy. 
Anorexia  is  not  a  rare  accompaniment  of  gastric  ulcer,  and  even  the  chem- 
istry ^"  of  the  gastric  juices  is  frequently  alike  in  so  far  as  the  findings 
of  HCl  are  normal. 

Gastric  Neuroses 

Gastric  neuroses  occurring,  for  instance,  at  the  time  of  the  menopause, 
frequently  awaken  the  suspicion  of  carcinoma  because  of  the  severe  ano- 
rexia, continued  gastric  pressure  and  rapid  emaciation. 

Acute  Gout 

I  have  also  seen  acute  attacks  of  gout  run  a  course  of  man}'  weeks 
accompanied  b}'^  severe  anorexia  and  a  particular  disgust  for  meat. 

Trichohezoar 

"Hair  tvnnors"  of  the  stomach  are  probably  a  rare  cause  of  mistaken 
diagnosis. 

^'  Perigastric  tumors  with  gastric  ulcer  count  among  the  greatest  rarities. 
'"  The   cases    of    gastric    ulcer    observable    in    Vienna,    as    a    rule,    show   no    hyper- 
chlorhydria.  * 


102 


TUMORS    OF    THE    ABDOMINAL    VISCERA 


Tuberculosis 

Consumptives  often  suffer  from  anorexia,  and  the  suspicion  of  can- 
cer in  these  cases  may  be  strengthened  by  the  more  or  less  high  degree  of 
cachexia  produced  by  the  underlying  ailment.  Aside  from  that,  many 
cases  of  tuberculosis  are  accompanied  by  subacidit}^  and  even  achlorhy- 
dria ;  furthermore,  in  senile  phthisis  the  pulmonary  symptoms  are  not 
prominent  or  are  obscured  by  an  accompanying  emphysema. 

The  motor  function  of  the  stomach,  however,  is  usually  intact.  The 
absence  of  "occult"  melena  deserves  particular  and  full  attention. 

Pernicious  Anemia 

The  same  is  true  of  pernicious  anemias,  which  from  their  general 
aspect  may  easily  awaken  the  suspicion  of  gastric  carcinoma.  Among 
the  symptoms  which  occasionally  are  common  to  both  we  might  mention : 
emaciation,  pronounced  feeling  of  weakness,  pallor,  anorexia  with  dis- 
gust for  meat,  achlorhydria,  sporadic  lactic-acid  bacilli  in  the  feces, 
epigastric  tenderness  to  pressure  (in  pernicious  anemia  being  due  to  hy-. 
peremia  of  the  liver),  epigastric  resistance  (enlargement  of  the  liver  and 
spleen !). 

For  a  rapid  differentiation  we  might  consider  the  following: 


"Anemic"  Type  of  Gastric  Cancer. 
Obstipation. 

Tumor  of  the  spleen  rare. 

Rarely  any  tenderness  to  pres- 
sure over  the  lower  half  of  the 
sternum. 


Occult  "melena." 
Lactic-acid     bacilli     in     the 
often  very  abundant. 


fe( 


Pernicious  Anemia. 

Diarrheas     often     dating     back     a 

number  of  years. 
Tumor  of  the  spleen  frequent. 


Blood  test  of  feces  negative. 

Few  lactic-acid  bacilli  in  the  feces; 
often  abundant  presence  of 
cocci. 


In  this  way  the  differential  diagnosis  may  frequently  be  made  with 
great  probability  even  without  a  blood  examination. 

Tuhercular  Serositis 

Confusion  with  tubercular  serositis  may  occur,  especially  in  case  of 
the  peritoneal-pleural  types  (see  page  98)  of  gastric  cancer,  and  that 
so  much  the  easier  when  we  are  dealing  ^^nth  youthful  individuals,  in 
whose  cases  we  are  less  apt  to  think  of  malignant  diseases. 

Thus  I  recall  the  case  of  a  girl,  18  years  of  age.  During  life  The. 
serosarum  was  thought  of.  Autopsy  disclosed  a  soft  carcinoma  of  the 
greater  curvature,  lymphatic  metastases  into  the  peritoneum  and  pleura 
with  hemorrhagic  effusions. 

Such  cases  sometimes  run  a  moderately  febrile  course  and  occasion- 
ally are  accompanied  by  diazo-reaction,  as  so  often  almost  regularly  hap- 


CANCER    OF    THE    STOMACH  103 

pens  in  tuberculosis  of  the  peritoneum.  Carcinomatous  infiltration  of  the 
umbilicus  (5.*J),  good  motility  of  pleural  effusions,  "occult  melena," 
copious  vegetations  of  lactic-acid  bacilli  in  the  feces  and  strongly  hem- 
orrhagic or  "milky"  character  of  the  ascitic  fluid  may  occasionally  be 
findings  which  rapidly  decide  in  favor  of  the  diagnosis  of  carcinoma. 

Abscess   of   the  Liver 

Uniform  diffuse  metastasis  into  the  liver  (40,  82)  may  also  be  very 
misleading,  especially  if  accompanied  by  nmch  painfulness  and  fever. 
Here  there  is  a  possibility  of  making  the  wrong  diagnosis  of  abscess  of 
the  liver,  cholangitis,  echinococci,  etc. 

On  the  other  hand,  cases  of  gastric  or  duodenal  ulcer  with  secondary 
abscesses  of  the  liver  may  easily  lead  to  the  assumption  of  gastric  car- 
cinoma with  metastasis  in  the  liver. 

Neurasthenia 

Where  a  gastric  cancer  develops  in  a  neuropathic  individual  there  is 
danger  of  confusing  an  organic  with  a  functional  disease. 

Thus  in  one  case  the  disease  manifested  itself  with  a  voracious  appe- 
tite;  another  complained  of  burning  in  the  stomach,  "as  if  a  lamp  were 
in  it." 

The  symptom  picture  in  such  cases  readily  assumes  neuropathic  traits. 

Organic  lesions  of  the  nervous  system  may  come  into  the  foreground 
and  obscure  the  primary  disease  process. 

Neuralgias 
Hemiplegia 

Thus  in  one  case  there  existed  very  severe  neuralgias  which  were  the 
result  of  metastases  in  the  spinal  column ;  in  another  case  there  was  hemi- 
plegia due  to  embolism  from  an  ulcerating  endocarditis  (infection  from 
the  ulcerating  surface.''). 

Senile   Tuberculosis 

It  has  already  been  stated  that  in  cases  of  senile  tuberculosis  one  may 
easily  be  falsely  suspicious  of  cancer  of  the  stomach.  But  mistakes  can 
also  be  made  in  the  opposite  direction. 

I  have  in  mind  a  case  in  which  tuberculosis  was  thought  of  on  ac- 
count of  hemoptysis,  and  the  autopsy  revealed  metastases  in  the  lungs ; 
in  another  observation  there  was  a  combination  of  pulmonary  cavity  and 
gastric  cancer.  I  have  also  observed  multiple  caries  of  bones  and  can- 
cer of  the  stomach.  Mediastinal  gland  metastases  may  provoke  delusory 
attacks  of  asthma,  or  the  finding  of  a  purulent  left-sided  pleural  effusion 
may  cause  one  to  overlook  the  primary  disease  of  the  stomach.  Early 
carcinomas,  occurring  about  the  fortieth  year,  are  very  frequenth'  accom- 
panied by  healed  tubercular  foci. 
Addison 

Adynamia,  together  with  bronzed  discoloration  of  the  skin,  may  lead 
us  to  think  of  Addison's  disease  when  there  is  really  a  gastric  cancer 
(see  page  47). 


104  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Intestinal  Stenosis 

The  symptoms  of  secondary  intestinal  stenosis  may  also  obscure  the 
clinical  picture  of  carcinoma  of  the  stomach.  Thus  increased  gastric 
peristalsis  frequently  exists  with  moderate  rigidity  of  the  bowel;  but 
there  may  also  be  real  stenosis  of  the  bowel  even  to  the  occurrence  of 
ileus,  due  to  metastases  in  the  pouch  of  Douglas,  invasion  of  the  colon  or 
metastasis  in  the  mesentery  of  the  small  intestine  together  with  con- 
traction. 

Endocarditis,  etc. 

Occasional  cardiac  complications  are  ulcerating  endocarditis  and 
peritonitis,  in  which  cases  we  are  apt  to  consider  the  ulcerating  surface 
as  the  source  of  the  infectious  excitants. 

Meningitis 

A  complicating  infectious  process  that  I  saw  in  one  case  was  the 
occurrence  of  streptococcic  meningitis   (54). 

Complications  of  this  kind  are  apt  to  attract  the  entire  attention  of 
the  observer. 

Perforating  Peritonitis 

The  same  holds  good  of  perforative  peritonitis  (23,  74)  occurring 
acutely  with  chills  and  abdominal  pains. 

Abscess  of  Abdominal   Walls 

Abscesses  of  the  abdominal  walls  should  always  be  investigated  with 
reference  to  their  possible  connection  with  carcinoma  of  the  stomach. 

In  the  differential  diagnostic  considerations  so  far  we  have  dealt  with 
the  possibility  of  mistake  between  gastric  cancer  and  non-neoplastic  dis- 
eases of  organs. 


There  still  remains  to  be  considered  the  possibility  of  mistakes  be- 
tween gastric  cancer  and  other  neoplasms. 

Carcinoma  of  the  Esophagus 

Deep-seated  carcinoma  of  the  esophagus  might  be  considered  first.  If 
this  condition,  as  is  often  the  case,  causes  no  difficulties  in  swallowing, 
then  the  sum  of  the  clinical  symptoms — including  demonstration  of  blood 
in  the  feces — very  often  entirely  answers  the  description  of  gastric  can- 
cer, only  there  is  no  palpable  tumor.  The  subjective  complaints  are  fre- 
quently referred  to  the  epigastrium.  A  wrong  diagnosis  in  these  cases 
could  easily  lead  to  a  useless  operation ;  this  possibility,  therefore,  must 
always  be  reckoned  with  when  the  findings  by  palpation  are  deficient. 
However,  the  reverse  error  is  also  possible  where  a  gastric  cancer  is 
situated  high  up  where  a  scirrhus  carcinoma  infiltrating  the  entire  stom- 
ach causes  stenosis  of  the  cardia  (10). 


CANCER    OF    THE    STOMACH  105 

Carcinoma  of  the   Colon 

Tumors  situated  in  the  median  line  of  the  epigastrium  ought  never 
to  be  referred  to  the  colon,  but  rather  to  the  stomach,  as  the  middle  por- 
tion of  the  transverse  colon  almost  never  becomes  carcinomatous. 

Rectal  Carcinoma 

At  times  rectal  carcinomas  are  erroneously  assumed  in  these  cases 
where  we  are  dealing  with  stenosis  caused  by  gastric  cancer  metastases  in 
the  pouch  of  Douglas. 

Cancer  of  the  Gail-Bladder 

Moreover,  carcinoma  of  the  gall-bladder  when  running  its  course  with- 
out icterus  and  stenosing  the  pylorus  may  easily  be  mistaken  for  cancer 
of  the  pylorus.  Under  these  circumstances  there  may  even  occur  "cof- 
fee-ground" vomiting  and  copious  vegetation  of  lactic-acid  bacilli.  A 
history  of  cholelithiasis  and  the  occasional  unusual  degree  of  gastric  dila- 
tation will  admonish  one  to  be  cautious. 

Ovaries 

Ovarian  metastases  may  be  mistaken  for  a  primary  tumor. 

Bone  Tumors 

It  is  extraordinarily  rare  that  metastatic  bone  tumors  give  occasion 
for  confusion  with  primary  bone  tumors. 

I  remember  a  case  in  which  the  assumption  was  osteosarcoma  of  the 
thigh.     Autopsy:  primary  carcinoma  of  the  stomach. 

The  combination  of  gastric  ulcer  and  tumors  of  Grawitz,  which  I 
can  remember  having  met,  can  easily  give  rise  to  the  wrong  diagnosis  of 
a  gastric  neoplasm.  In  one  case  there  was  present  even  "coffee-ground" 
vomiting  with  copious  vegetation  of  lactic-acid  bacilli  and  achlorhydria. 
Autopsy:  Cicatricial  benign  stenosis  of  the  pylorus  and  Grawitz  tumor. 

Renal  Neoplasms 

Case  90  illustrates  the  possibility  of  confusion  between  gastric  and 
renal  neoplasms.  This  mistake  is  occasionally  favored  by  the  fact  that 
the  painful  sensations  in  gastric  cancer,  even  though  seldom,  may  be  to 
a  greater  extent  localized  posteriorly  in  the  left  or  right  kidney  region. 


Carcinoma  of  the  Large  Intestine 

Stenosis,*'^  secondary  catarrh  of  the  large  intestine  and  ulceration  are 
the  factors  which,  from  internal  necessity,  comprise  the  entire  sympto- 
matology of  carcinoma  of  the  large  bowel,  at  least  in  so  far  as  the  intes- 
tinal tube  as  such  is  concerned.  From  this  there  also  results  the  varie- 
gated row  of  symptoms  which  are  designated  as  early  symptoms  and 
which  will  be  discussed  in  the  following  pages. 

EARLY    SYMPTOMS 

1.    Fain  Phenomena 

In  many  cases  they  introduce  the  clinical  manifestations  and  precede 
the  objective  findings.  An  exact  estimate  of  their  value  in  a  given  case 
belongs  to  the  most  important  requisition  of  an  early  diagnosis  in  this 
domain. 

Atiacl's  of  Colic 

Attacks  of  colic,  otherwise  unaccountable  or  apparently  caused  by  a 
dietetic  error,  are  not  seldom  the  first  signal  of  alarm. 

In  these  cases  the  first  important  thing  is  to  correctly  interpret  the 
character  of  the  colicky  attacks  and  discover  their  intestinal  origin.  In 
this  respect  the  fullest  attention  is  due  to  the  auscultatory  phenomenon 
of  "borborygmi,"  often  increasing  to  the  extent  of  "bowel  roaring,"  and 
also  in  the  taking  of  histories  it  would  be  well  to  make  inquiries  in  regard 
to  this  when  there  is  question  of  colicky  attacks. 

This  auscultatory  phenomenon  often  precedes  visible  peristalsis  by  a 
long  interval.  The  attacks  of  colic  that  are  observed  in  connection  with 
intestinal  carcinoma  are  mostly  due  to  obstruction  and  increased  peristal- 
tic efforts  of  the  portion  of  intestine  lying  ahead  of  the  point  of  ob- 
struction. 

Topography 

I  consider  radiation  of  pain  toward  the  anal  opening  occasionally  ac- 
companied by  rectal  tenesmus  "-  a  very  important  mark  of  recognition, 
belonging  especially  to  carcinoma  of  the  large  intestine. 

Another  factor  that  will  speak  for  the  intestinal  origin  of  the  pains 

"  Functionally  equivalent  to  stenosis  we  must  consider  disturbed  motility  or  entire 
cessation  of  it  in  a  circumscribed  portion  of  gut  invaded  by  carcinoma. 
*^  Ca.  flex,  sigm.,  1,  5;  Ca.  recti,  6. 

106 


CARCINOMA    OF    THE    LARGE    INTESTINE  107 

is  that  they  occur  iinmedijitcly  l)cfore  or  together  with  bowel  evacuation 
or  are  accompanied  by  violent  tenesmus. 

Less  certain  than  the  criteria  just  mentioned  and  sometimes  directly 
misleadincr  are  other  topographical  relations  of  intestinal  colics. 

Thus  with  deep-seated  carcinoma  the  radiation  may  occasionally  oc- 
cur in  tiie  left  testicle  (Ca.  recti,  11). 

As  a  rule,  we  find  it  localized  around  the  umbilicus  or  spread  diffusely 
over  the  lower  abdominal  region. 

In  some  cases  the  situation  of  the  intestinal  colic  corresponds  to  the 
seat  of  the  disease,  the  colicky  pains  being  locally  limited,  and  if  cor- 
rectly diagnosed  as  intestinal  colic  this  local  situation  will  lead  one  to 
think  of  a  local  cause  which  most  frequently  turns  out  to  be  a  carcinoma. 

Thus,  when  the  carcinoma  is  situated  in  the  hepatic  flexure,  the  colics 
may  be  located  to  the  right  of  and  above  the  umbilicus  (Ca.  flex,  hepat., 
3),  or  if  the  descending  colon  and  sigmoid  flexure  be  affected,  they  are 
more  localized  on  the  left  side,  the  point  of  emanation  being  in  the  left 
half  of  the  epigastrium  or  the  left  lower  abdominal  region  (Ca.  recti,  9). 
Radiations  into  the  back  and  loins  count  among  the  most  fi'equent  ob- 
servations. 

Influences 

Alimentary  influences  sometimes  figure  in  the  provocation  and  con- 
trol of  colicky  attacks ;  such  fermentable  foods  as  bread,  dumplings, 
legumes,  etc.,  being  chiefly  blamed. 

AVith  this  in  view  it  occasionally  may  be  advisable  for  diagnostic  rea- 
sons to  undertake  experimental  tests  along  these  lines. 

Frequently  it  is  impossible  from  the  history  to  determine  a  definite 
relation  to  the  mode  of  nutrition,  as  there  exist  seemingly  paradoxical 
relations,  such  as  improvement  in  the  subjective  complaints  after  the  in- 
take of  foods  "^"^  which  are  difficult  to  digest,  e.g.,  sauerkraut,  probably 
because  of  their  laxative  action. 

The  general  pathogenesis  of  intestinal  colics,  in  which  ovcrdistcntion  of 
the  bowel-Avalls  by  gas  plays  an  important  part,  will  account  for  the  fact 
that  the  elimination  of  feces  and  gases  in  most  instances  affords  prompt 
relief  from  pain. 

In  one  case,  for  instance  (flex,  hepatic,  1),  colic  was  regidarly  pro- 
voked by  lying  down  immediately  after  eating. 

I  also  recall  a  case  of  carcinoma  of  the  hepatic  flexure  in  which  un- 
covering of  the  legs  or  walking  on  a  cold  floor  sufliced  to  induce  colic. 
This  behavior  was  of  decisive  significance  for  the  differential  diagnosis  of 
gall-stone  colic  and  intestinal  colic. 

A  Karlsbad  "drink  cure"  may,  under  some  circumstances,  also  occa- 
sion colics  in  case  of  latent  carcinoma  of  the  large  bowel  (flex,  lienal,  1). 

The  fact  that  colics  set  in  or  become  aggravated  with  certain  posi- 
tions of  the  body  may  be  important,  since  such  behavior  points  to  a  local 
cause. 

"  Ca.  flex,  hepat.,  1. 


108  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Thus  in  one  case  (Ca.  fiex.  lienal,  1)  lying  on  the  left  side  caused  in- 
creased severity  of  the  colicky  pains. 

Also  in  this  domain  there  are  "painful  attitudes"  which  have  long 
ago  been  recognized  in  the  symptomatology  of  gastric  ulcer. 

Time  of  Occurrence 

The  time  relations  of  the  colics  offer  practically  no  diagnostic  advan- 
tages and  can  rather  be  misleading. 

Thus  I  recall  a  case  (Ca.  ceci,  4)  in  which  the  pains  began  imme- 
diately after  the  intake  of  food  and  were  localized  in  the  epigastrium; 
in  another  case  (Ca.  flex,  hepat.  1)  the  interval  amounted  to  five  hours. 
This,  in  conjunction  with  gastric  symptoms,  such  as  vomiting,  sour  eruc- 
tation, hiccough,  could  be  misleading  if  too  much  diagnostic  value  is  at- 
tached to  relation  in  time  between  food  intake  and  beginning  of  pain, 
unmindful  of  the  fact  that,  figuratively  speaking,  the  gastro-intestinal 
tract  acts  like  a  worm,  which,  when  irritated  in  one  place,  will  twist  and 
turn  throughout  its  length.  The  intake  of  food  is  just  such  an  irrita- 
tion, and  in  case  of  an  irritable  condition  of  the  large  gut  ma}'  elicit  such 
immediate  reaction. 

Intestinal  colics  share  in  the  general  preference  of  all  colics,  includ- 
ing physiological  uterine  pains,  to  appear  at  night. 

In  contradistinction  to  other  colics  (gall  and  kidney  stones),  the 
colics  observed  with  carcinoma  of  the  large  intestine  are  but  seldom  ac- 
companied by  chills  (Ca.  flex,  hepat.,  3)  ;  whereas  moderate  rises  in  tem- 
perature are  frequently  met  with;  they  originate  in  the  ulcerating  process. 

If  in  connection  with  cancer  of  the  large  intestine  we  make  the  obser- 
vation that  at  times  attacks  of  colic  are  absent  unto  the  end,  whilst  in 
other  cases  they  are  the  first  manifestations  of  the  disease,  it  is  quite 
analogous  to  other  diseases  (e.g.,  gall-stones)  in  which  we  expect  to  find 
colics. 

In  the  later  stages  it  is  chiefly  the  organic  stenosis  which  is  at  the 
bottom  of  the  colics ;  in  the  beginning,  but  also  later  on,  the  same  effect 
is  produced  functionally  by  disturbed  motility  of  the  portion  infiltrated 
by  cancer  or  by  spastic  contractile  conditions  of  the  same ;  secondary  in- 
flammatory complications  of  the  large  intestine  augment  the  disposition 
to  painful  attacks.  At  any  rate,  the  intestinal  colics  just  discussed  often 
precede  by  a  long  interval  the  objective  symptoms  of  stenosis,  such  as 
visible  peristalsis,  cessation  of  fecal  and  gaseous  elimination,  fecal  vomit- 
ing, etc.,  and  herein  lies  their  importance,  which  cannot  be  overestimated 
for  the  early  diagnosis  of  intestinal  cancer.  While  frequently  occurring 
at  the  height  of  obstipation,  they  sometimes  also  set  in  when  there  is 
fairly  regular  bowel  evacuation  (Ca.  flex,  lien.,  1). 

However,  they  may  also  be  absent  with  the  severest  obstipation  (Ca. 
recti,  5),  not  occur  at  all  (Ca.  ceci,  2),  or  set  in  only  during  the  later 
stages  of  the  disease  (Ca.  flex,  lien.,  1;  ceci,  1).  This  is  simply  an  evi- 
dence of  the  caprice  characterizing  the  relation  of  colicky  attacks  for  the 
processes  on  which  they  depend.     The  absence  of  colics,  therefore,  can 


CARCINOMA    OF    THE    LARGE    INTESTINE  109 

never  be  construed  against  the  diagnosis  of  a  possible  carcinoma  of  the 
large  intestine. 

In  a  subsequent  chapter  those  factors  will  be  summed  up  which  would 
seem  suitable  to  impart  to  intestinal  colics  an  especial  value  for  the 
diagnosis  of  intestinal  cancer. 

The  pain  phenomena  hitherto  discussed  were  more  or  less  diffuse  and 
characterized  by  their  colicky  character. 


The  development  of  cancerous  growths  in  certain  sections  of  the  bowel 
also  leads  to  localized,  more  circumscribed  sensations  of  pain  without 
definite  nuance,  which  deserve  careful  attention  as  local  symptoms. 

Tenderness  on  Pressure 

In  every  abdominal  examination  at  least  the  cecum  and  the  three 
flexures  should  be  tested  for  any  possible  tenderness  to  pressure,  and  it 
will  be  advisable  to  palpate  the  splenic  flexure,  as  in  palpation  of  the 
spleen,  with  the  body  lying  on  the  right  side.  Neoplasms  of  the  in- 
testine are  almost  always  more  or  less  tender  to  pressure. 

Carcinoma  of  the  sigmoid  flexure  not  infrequently  occasions  localized 
spontaneous  pains,  in  connection  with  which  radiation  may  occasionally 
be  observed  along  the  left  spermatic  cord  into  the  left  testicle ;  bowel 
movements  at  times  afford  relief.*'"' 

Lumbar   Pains 

Continued  pains  in  the  back  do  not  occur  according  to  my  expe- 
rience even  with  deep-seated  intestinal  cancer  (Flex.  sigm.  and  rectum) 
as  frequent  findings.  If  they  occur  at  all  they  have  less  connection  with 
the  neoplasm  as  such  and  are  not  to  be  looked  upon  as  a  local  symptom. 

Not  rarely,  however,  they  fall  within  the  area  of  the  radiations  of 
attacks  of  colic  and  occur  synchronously  with  them ;  therefore,  the}'  also 
evince  occasional  dependence  upon  alimentary  influence  (Ca.  flex,  sigm., 
5).  Even  with  very  extensive  metastases  in  the  retroperitoneal  glands, 
they  may  be  entirely  absent  (Ca.  flex,  sigm.,  2).  Occasionally  they  seem 
to  have  some  connection  with  ascites  and  disappear  after  its  removal. 
Emaciation  as  such  may  sometimes  elicit  them,  this  being  a  well-known 
phase  of  antifat-cures.  They  may,  furthermore,  depend  on  accumu- 
lation of  fecal  masses,  the  removal  of  which  is  followed  by  their  temporary 
disappearance.  Finally  these  symptoms  may  also  be  occasioned  by  metas- 
tases in  the  liver  just  as  they  give  rise  to  painful  sensations  in  the  epigas- 
trium. Pains  in  the  sacral  region  seem  to  me  to  be  more  closely  related 
in  a  causal  way  to  deep-seated  intestinal  carcinoma,  such  pains  also  being 
met  with  in  hemorrhoidal  conditions. 

Painful  Positions 

"Painful  position"  may  be  brought  about  in  several  ways.  They  may 
be  caused  by  the  weight  of  tumor-masses,  which  lose  their  points  of  sup- 
port when  the  body  assumes  certain  positions. 

"  Ca.  flex,  sigm.,  2,  4. 


110  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Thus  in  tumors  of  the  cecum,  left-sided  decubitus  causes  especial 
discomfort  and  there  is  observable  a  painful  pulling  toward  the  left,  or 
with  certain  lateral  decubitus  there  may  ensue  colicky  pains  (increase  of 
the  stenosis  through  pressure,  kinking,  etc.). 

But  also  severe  tension  of  the  abdominal  walls  from  meteorism  some- 
times seems  to  prohibit  lateral  decubitus,  this  being  almost  invariabl}'^ 
so  when  there  have  been  added  acute  peritonitic  complications. 

These  would  be  suspected,  especially  when  the  pains  set  in  acutely 
above  the  symphisis,  and  are  accompanied  by  chills,  collapse,  and  severe 
rigidity  of  the  abdominal  walls.     (Ca.  recti,  2.) 

2.  Disturbances  of  the  Motor  Function  of  the  Bowel 

From  this  there  result  in  the  first  place  symptoms  on  the  part  of 
the  bowel ;  furthermore  in  a  great  number  of  cases  there  are  also  gastric 
symptoms. 

a.  Intestinal  Symptoms 

There  is  a  close  analogy  between  carcinomas  which  develop  in  the 
sigmoid  flexure  and  carcinomas  of  the  pylorus,  severe  stenosis  being  of 
frequent  occurrence.  The  more  solid  consistence  of  the  feces  in  this 
terminal  portion  of  the  large  intestine  may  be  considered  a  favoring 
factor  for  the  occurrence  of  stenosis  manifestations.  Deep-seated  car- 
cinomas of  the  large  intestine,  therefore,  more  frequently  lead  to  severe 
stagnation  of  fecal  masses,  i.e.,  obstinate  obstipation. 

In  these  cases,  especially  when  there  is  circular  extension  and  the 
cancer  is  of  a  scirrhus  nature,  there  easily  ensues  severe  organic  stenosis. 

It  is  important  to  know  that  obstipation  due  to  carcinoma  of  the  large 
intestine  not  infrequently  shows  deceptive  remissions  (Ca.  flex,  sigm.,  4). 
These  may  be  explained  by  compensatory  hypertrophy  of  the  portion 
of  bowel  above  the  stenosis  or  to  an  opening  of  the  passage  through 
ulceration ;  occasionally  there  may  come  into  consideration  causative  fac- 
tors which  act  as  curative  in  habitual  constipation,  such  as  diet,  move- 
ments, general  improvement  of  bodily  constitution  through  sojourn  in  the 
country,  etc. 

In  the  later  stages  of  the  disease,  often  the  initial  obstipation  occurring 
with  cancer  of  the  rectum  and  sigmoid  changes  to  the  opposite,  at  least, 
in  so  far  as  copious  evacuations  occur  accompanied  by  violent  tenesmus. 
Indeed,  the  stagnation  of  fecal  masses  continues  undiminished,  and  it 
would  be  fallacious  in  these  instances  to  speak  of  "diarrhea";  examination 
per  rectum  and  externally  discloses  the  presence  of  old,  caked  scybala. 
The  evacuations  are  frequently  not  fecal  discharges  but  consist  of  mucus, 
blood  and  pus. 

It  is  very  noteworthy  that  these  copious  evacuations  are  scarcely  ever 
influenced  by  therapeutic  measures  directed  against  chronic  intestinal 
catarrh  such  as  diet,  rest  in  bed,  astringents,  opium  preparations,  etc., 
and  this  may  occasionally  serve  as  a  diagnostic  reminder. 

With  carcinoma  of  the  rectum  we  also  meet  with  disturbances  of  mo- 


CARCINOMA    OF    THE    LARGE    INTESTINE  111 

tility,  such  as  incontinence.  During  the  course  of  a  long-continued  obsti- 
pation there  may  suddenly  occur  irresistible  tenesmus  and  involuntary 
bowel  movement. 

The  separate  evacuation  of  urine  and  feces  is  also  frequently  inter- 
fered with. 

Similarly  retention  of  larger  enemas  becomes  impossible  and  prolapses 
may  easily  occur  (Ca.  recti,  2). 

Cancers  developing  in  the  cecum,  in  the  hepatic  and  splenic  flexures, 
are  less  frequently  accompanied  by  severe  obstipation  than  the  deep- 
seated   neoplasms   just   discussed. 

As  the  lumen  of  the  bowel  in  the  former  is  larger,  the  cancers  are 
often  mural,  not  circular,  and  leave  an  open  passage  as  a  result  of  ulcer- 
ation ;  moreover,  the  contents  of  the  upper  portion  of  the  large  intestine 
are  less  consistent.  Infiltration  of  the  bowel  as  such  may  in  a  functional 
way  be  equivalent  to  a  stenosis,  and  if  in  addition  to  this  there  occur 
acute  insufficiency'"'-'*  of  the  section  of  bowel  lying  ahead,  the  conditions  are 
at  hand  for  the  occurrence  of  ileus. 

Just  as  obstinate  obstipation  is  not  frequent  with  this  kind  of  cancer 
of  the  large  intestine,  so  also  profuse  diarrheas  are  not  the  rule. 

Mild  obstipation  alternating  with  mild  diarrheas  is  probably  more  fre- 
quent, the  variations  from  the  normal  often  being  very  slight  (Ca.  flex. 
hep.,  1;  flex,  sigm.,  2). 

This  is  one  of  the  chief  reasons  why  those  cancers  situated  in  the 
first  two-thirds  of  the  large  intestine  are  so  easily  overlooked. 

h.  Gastric  Symptoms 

These  deserve  full  attention,  because  not  infrequently  they  may  mis- 
lead in  diagnosis  and  deceive  one  into  assuming  an  independent  gastric 
disease. 

Such  a  mistake  is  likely  to  occur  ^*'  if  besides  anorexia  there  occur 
epigastric  pains,  heartburn,  eructation  of  gas,  inmiediately  after  the 
intake  of  food. 

In  one  of  my  cases  there  was  intolerance  for  sour  foods,  ingestion 
of  which  being  followed  by  instant  vomiting  and  troublesome  belching. 

In  discussing  the  pain  phenomena  it  has  already  been  pointed  out  that 
with  carcinoma  of  the  large  bowel,  the  appearance  of  intestinal  pain  may 
follow  immediately  the  ingestion  of  food. 

A  portion  of  the  gastric  symptoms,  e.g.,  heartburn,  is  evidently  re- 
ferable to  stagnation  of  stomach  contents,  which  in  its  turn  represents 
only  an  extension  of  intestinal  stagnation. 

From  it  there  results  decomposition  of  stomach  contents  and  re- 
gurgitation upward  which  manifests  itself  by  eructations  (tasteless,  sour 
or  foul  smelling),  heartburn,  nausea  and  vomiting,  as  well  as  anorexia. 

In  the  case  of  carcinoma  of  splenic  and  hepatic  flexures,  local  ad- 
hesions may  give  rise  to  disturbances  of  gastric  motility. 

'°  The  same  may  frequently  be  due  to  acute  overdistention  of  the  bowel-wall. 
••  Ca.  ceci,  3. 


112  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Vomiting  is  mostly  scant  and  less  of  an  alimentary  nature  than  in 
the  case  of  gastric  cancer,  occurring  mostlj'^  in  occasional  form  only,  but 
sometimes  characterized  by  special  stubbornness  (Ca.  recti,  14). 

It  sometimes  occurs  especially  after  the  use  of  sour  foods  (Flex,  lien., 
2),  or  after  prolonged  walking  (Cecum,  4)  and  sometimes  is  separated 
by  a  constant  interval  of  time  (2  hours),  from  the  time  of  eating  (Flex, 
lienal,  2). 

During  the  course  of  the  symptoms  of  stenosis  "coffee-ground"  vom- 
iting may  also  occur  (Flex,  sigm.,  5)  ;  this  might  be  attributed  to  severe 
distention  of  the  stomach  which  impedes  the  venous  flow. 

Since  the  gastric  symptoms  originate  in  disturbed  intestinal  function, 
it  is  easily  understood  that  they  should  be  subject  in  an  especial  degree 
to  influences  that  are  calculated  to  regulate  bowel  function  (bowl  washes, 
cathartics,  etc.),  more  so  than  is  the  case  in  gastric  cancer. 

The  occurrence  of  hiccough  (Ca.  flex,  lienal,  2),  which  sometimes  exists 
to  a  pronounced  degree  without  any  peritonitic  complications  might,  as 
in  pyloric  stenosis,  be  of  gastric  origin. 

Together  with  these  symptoms  of  gastric  origin  there  also  is  expe- 
rienced a  "sensation  of  pressure"  in  the  epigastrium,  which  is  occasionally 
found  regardless  of  the  location  of  cancer  of  the  large  intestine.  It 
sometimes  sets  in  inunediately  after  the  ingestion  of  food  and  may  be  ex- 
plained by  the  impeded  emptying  of  the  stomach. 

In  these  cases  it  would  also  be  well  to  determine  whether  there  might 
not  be  intumescence  of  the  liver  as  a  result  of  metastasis.  Also  local 
states  of  distention  of  the  large  intestine  above  the  diseased  portion  of 
the  bowel  may  manifest  themselves  by  a  more  or  less  painful  sensation 
of  epigastric  pressure,  and  it  has  already  been  pointed  out  that,  espe- 
cially with  deep-seated  cancer  of  the  bowel,  the  origin  of  the  attacks  of 
colic  is  not  infrequently  situated  in  the  epigastrium  (Ca.  flex,  hepat,,  2). 

The  appetite  frequently  remains  remarkably  good  (Ca.  recti,  5,  12; 
Ceci,  2) ;  occasionally  it  is  only  the  fear  of  aggravation  of  the  feeling 
of  abdominal  distress  which,  despite  good  appetite,  keeps  the  patient 
from  ingesting  larger  quantities  of  food  (Ca.  flex,  sigm.,  10)  ;  in  other 
cases  there  exist  anorexia,  which  sometimes  is  limited,  as  in  gastric  cancer 
especially,  to  the  use  of  meat  (Ca.  flex,  hepat.,  1). 

3.  Hemorrhage 

Copious  hemorrhages  from  the  ulcerating  neoplasm  are  probably  of 
extremely,  rare  occurrence  with  intestinal  carcinoma  and  then  almost  al- 
ways occur  in  rectal  or  sigmoid  cancer;  but  even  in  these  cases  there  is 
a  far  more  frequent  discharge  of  blood-colored  mucous  masses  resembling 
that  of  dysentery. 

Tar-colored  stools  are  never  observed. 

In  carcinoma  of  the  cecum  and  both  upper  flexures  the  stools  mostly 
give  no  macroscopic  hint  of  blood ;  only  the  admixture  of  mucus  not 
infrequently  shows  a  dark  red  color.  As  cancer  of  the  large  intestine 
is  often  complicated  with  hemorrhoidal  conditions,  it  becomes  very  diffi- 


CARCINOMA    OF    THE    LARGE    INTESTINE  11. 'J 

cult,  at  times,  to  decide  how  cheinicnlly  demonstrable  blood  may  be  traced 
to  its  source. 

Precisely  in  these  cases,  the  uselessness  of  those  methods  which  en- 
deavor to  prove  even  the  minutest  traces  of  blood,  is  made  clear  and 
the  advantages  of  a  coarser  technique  of  examination  become  apparent. 
With  regard  to  this,  reference  may  be  made  to  former  discussions.  A 
constantly  negative  finding  of  blood  coloring  matter  would  at  any  rate 
admonish  to  greatest  caution  in  making  the  diagnosis  of  cancer  of  the 
large  intestine,  especially  if,  at  the  same  time,  the  supposedly  ulcerating 
surface  be  mechanically  irritated  by  the  ingestion  of  food  rich  in  cellu- 
lose, such  as  bran-bread. 


PHYSICAL   EXAMINATION   FOR   CARCINOMA   OF   THE 
LARGE    INTESTINE 

1.  Palpation 

Simplest  of  all,  is  the  demonstration  by  palpation  of  deep-seated  rectal 
carcinomas ;  wherefore,  the  frequenc}-  of  wrong  diagnosis  in  this  domain 
presents  a  glaring  contrast. 

Diagnoses  like  "hemorrhoids,"  "chronic  catarrh  of  the  large  bowel," 
are  of  daily  occurrence. 

Omission  of  digital  examination  of  the  rectum  is,  in  many  of  these 
cases,  a  punishable  offence. 

Uncommon  size  of  the  empty  ampulla^'^  may  occasionally  be  a  suspi- 
cious factor  in  carcinoma  situated  high  up  in  the  rectum  or  deep-seated  in 
the  flexure,  and  urge  to  repeated  digital  exploration.  For  the  height — 
particularly  the  depth — of  these  cancers  changes  and  depends,  in  part, 
upon  the  degree  of  abdominal  meteorism  and  the  suprastenotic  accumula- 
tion of  feces. ''^     Hence,  not  one  but  several  examinations. 

For  the  rest,  when  there  is  suspicion  of  carcinoma  of  the  large  in- 
testine, particular  attention  will  have  to  be  shown  the  angles  of  the 
imaginary  square  represented  by  the  large  bowel  (cecum  and  the  three 
flexures),  the  more  so  when  in  the  general  orientation  one  of  these  places 
displays  special  tenderness  to  pressure.  Severe  tension  of  the  abdominal 
walls,  through  gaseous  distention  of  the  intestine,  often  adds  to  the 
difficulties  of  palpation  and  should  always  be  eliminated  as  far  as  pos- 
sible.«'-^ 

The  situation  of  the  tumors  usually  corresponds  to  their  point  of 
origin. 

It  is  probably  very  rare  that  carcinomas  of  the  rectum  (Ca.  recti, 
8)  give  occasion  for  the  appearance  of  cancerous  tumors  that  can  be 
felt  through  the  abdominal  walls. 

Cancers  of  the  sigmoid  flexure  are  removed  from  the  belly-wall,  and 
especially  with  ascites  can  only  be  reached  by  intermittent  deep  palpa- 

"  Hochenegg,  Wiener  klin.  Wochenschr.,  1897,  No.  32. 
"'  In  regard  to  instrumental  examination,  see  page  6. 
•"  See  page  2. 


114  TUMORS    OF    THE    ABDOMINAL    VISCERA 

tion.  They  may  occasionally  be  located  almost  in  the  median  hnc  of 
the  lower  abdominal  region  (Ca.  flex,  sigma.,  6)  and  sometimes,  analogous 
to  tumors  of  the  pylorus,  exhibit  the  phenomenon  of  "wandering."  In 
case  of  scirrhus,  circular  cancers  of  the  sigmoid,  which  in  fact  are  not 
palpable  because  there  is  no  real  tumor  formation,  it  can  easily  happen 
that  the  fecal  masses  which  become  caked  into  hard  balls,  may  be  mis- 
taken for  the  tumor. 

Cancers  of  the  splenic  flexure,  on  account  of  their  hidden  position, 
could  most  easily  escape  discovery;  in  the  examination  of  this  flexure  it 
would  seem  to  me  most  proper  to  examine,  after  the  manner  of  splenic 
palpation,  and  also  bimanually,  as  for  kidney  tumors. 

Carcinoma  of  the  hepatic  flexure,  on  account  of  adhesions,  frequently 
does  not  permit  of  difl"ercntiation  from  the  border  of  the  liver. 

Palpation  should  also  always  include  observation  of  any  pulsations 
in  the  tumor-masses ;  their  presence  usualh^  indicates  that  the  tumor- 
masses  extend  backward  toward  the  abdominal  aorta,  or  have  come  into 
contact  with  the  latter  through  metastasis  into  the  retroperitoneal  glands 
(Ca.  ceci,  1;  flex,  hepat.,  1). 

Carcinoma  of  the  cecum  and  ascending  colon,  exhibit  frequently 
ballottement  by  bimanual  examination,  providing  they  extend  far  back 
into  the  lumbar  region;  less  critical  interpretation  of  this  s^^nptom  might 
result  in   falsely  diagnosing  tumors   of  the  kidne}'. 

Respiratory  mobility  of  tumors  of  the  cecum  is  usually  very  slight, 
but  never  entirely  absent. 

Besides  the  discovery  of  tumor-masses,  other  findings  as  well  must 
be  taken  into  consideration,  when  thei'c  is  suspicion  of  intestinal  cancer. 

Thus  the  state  of  rigidity  of  the  abdominal  wall. 

In  this  respect  the  flanks  deserve  especial  attention,  to  acquaint  one's 
self  with  the  amount  of  distention  of  the  ascending  and  descending  colon, 
if  there  is  no  ascites.  Thus  deep-seated  carcinomas  (Ca.  flex,  sigm.,  1,  9) 
sometimes  lead  to  marked  distention  of  the  descending  colon,  stenoses  of 
the  splenic  flexure  lead  to  increased  tension  on  the  right  side.  The  most 
suitable  method  of  testing  for  it  is  interrupted  palpation  with  the  flatly 
imposed  hand. 

By  means  of  the  gently  imposed  hand,  one  can  recognize  also  those 
first  degrees  of  increased  intestinal  peristalsis  whose  waves  the  eye  cannot 
clearly  detect  on  the  surface,  the  peristaltic  distention  of  the  bowel-loops 
which  manifests  itself  through  alternating  increase  and  decrease,  be  it 
local  or  diff'use,  of  abdominal  tension,  at  the  same  time  simultaneously 
occurring  intestinal  noises  can  often  be  better  identified  with  the  palpat- 
ing hand  than  with  the  ear. 

2.  Inspection '" 

The  visibility  of  increased  intestinal  peristalsis  naturally  depends 
upon  the  intensity  of  the  latter  and  also  the  degree  of  muscular  hyper- 

'°  In  regard  to  instrumental  examination  of  the  lower  bowel  segments  (Recto- 
Romanoscopy),  see  page  6. 


CARCINOMA    OF    THE    LARGE    INTESTINE  115 

trophy,  but  espccifilly  upon  the  condition  of  the  belly-walls  also.  The 
more  relaxed  ^ley  are,  the  more  easily  they  can  be  made  to  stand  out  by 
distended  segments  of  gut,  and  the  more  easily  also  they  adapt  them- 
selves to  their  movements. 

If  the  abdominal  musculature  be  tense  and  well  developed,  increased 
peristalsis  may  occasionally  lead  to  only  a  sudden  increase  in  the  size 
and  tension  of  the  abdomen,  but  without  the  appearance  of  isolated  seg- 
ments of  gut,  the  intestinal  noises  alone  calling  attention  to  peristaltic 
processes.  The  rapid  appearance  and  disappearance  of  such  a  "balloon 
belly"  is  proof  of  its  origin.  It  may  also  happen  that  distended  portions 
of  gut  arc  visible,  but  there  cannot  be  noticed  any  movements  of  the 
same. 

The  following  factors  are  of  importance  for  the  diagnosis  of  peristal- 
sis of  the  large  intestine  and  thus  of  some  obstruction  in  its  course. 

a.   Projection  of  the  contour  of  the  large  intestine. 

In  April,  1908,  a  woman,  63  years  old,  was  received  in  my  division 
(k.k.  Kaiserin  Elizabeth  Hospital).  Inspection  of  the  abdomen  led  to 
immediate  diagnosis,  viz.,  stenosis  in  the  region  of  the  hepatic  flexure  of 
the  colon.  The  first  thing  to  strike  the  eye  was  peristalsis  of  the  small 
intestine  localized  around  the  umbilicus,  and  in  addition  to  that,  as  a  sort 
of  culmination,  the  ascending  colon  stood  out  with  all  its  contour,  so  that 
this  portion  of  the  gut  could  be  recognized  beyond  a  doubt.  Autopsy 
performed  on  May  10,  1908  (Professor  Dr.  Fr.  Schlagenhaufer)  con- 
firmed the  localization  of  the  stenosis.     Cause:  Carcinoma  vesicae  felleje. 

This  case  illustrates  that  it  is  of  the  greatest  importance  to  deter- 
mine, if  possible,  where  the  peristalsis  ends. 

The  width  of  the  intestinal  loops  is  of  no  value  for  localization,  since 
loops  of  the  small  intestine  too  often  ai'e  subject  to  maximal  distention; 
it  might  carry  some  meaning  when,  with  very  thin  belly-walls,  there  were 
doubts  as  to  whether  the  peristalsis  was  physiological  or  pathological; 
the  former  takes  place  in  small  loops  of  intestine. 

h.   Isolated  peristalsis  and  distention  of  the  sigmoid  flexure. 

This  will  have  to  be  thought  of  if  an  intestinal  loop  projects  above 
Poupart's  ligament  on  the  left  side,  this  loop  collapsing  with  spontane- 
ous or  artificial  (rectal  tvibe)  discharge  of  flatus.  In  one  case,  for  in- 
stance (Ca.  flex,  sigiu.,  8),  the  peristaltic  projection  was  concurrent  with 
increased  filling  of  the  left  Yen.  epigastr.  inf. 

c.  Particular  state  of  tension  of  the  belly-wall  along  the  course  of  the 
ascending  or  descending  colon.  This  symptom  is  of  value  only  in  the 
absence  of  ascites,  and  gains  in  importance  if  it  be  unilateral. 

Bulging  in  the  usual  topographical  area  of  the  transverse  colon,  i.e., 
above  the  umbilicus,  may  occasionally  also  depend  upon  severe  distention 
of  the  small  intestine,  and  if  the  transverse  colon  does  not  stand  out 
prominently,  great  caution  is  in  order;  this  is  especially  true  if  there  is 
absent  increased  tension  on  the  right  side  or  on  both  sides. 

d.  Capacity  of  the  ampulla. 

e.  Radiation  of  the  colicky  pains  into  the  rectum. 
/.  Tenesmus. 


116  TUMORS    OF    THE    ABDOMINAL    MSCERA 

3.  Auscultation 

With  distended  loops  of  intestine,  as  met  with  in  carcinoma  of  the 
large  bowel,  even  when  there  is  no  stenosis,  the  heart-sounds  become  clearly 
resonant  and  are  heard  over  large  areas  of  the  abdomen.  Where  the 
question  of  meteorism  is  of  interest,  I  consider  this  symptom  very  worthy 
of  attention.  It  is  more  reliable  than  the  size  and  state  of  tension  of  the 
abdomen. 

Full  attention,  moreover,  is  due  those  rumbling,  oft  metallic,  squirt- 
ing sounds,  which  are  brought  about  through  the  movements  of  fluids  in 
the  large  gas-containing  recesses  of  greatly  distended  loops  of  the  intes- 
tine, when  assailed  by  the  peristaltic  waves.  It  will  be  well  to  note  its 
localization,  as  this  is  occasionally  in  relation  to  the  seat  of  the  stenosis. 
Thus,  in  one  case  of  carcinoma  of  the  cecum  (2),  their  seat  was  princi- 
pally in  the  left  half  of  the  abdomen ;  in  a  case  of  carcinoma  of  the  sig- 
moid flexure  (9)  they  occurred  mostly  along  the  course  of  the  descending 
colon.  It  is  of  advantage  to  auscultate  directly  with  the  ear,  without  a 
stethoscope. 

Furthermore,  attention  should  be  paid  to  peritoneal  friction-sounds  ^^ 
in  the  area  of  the  tumor  masses,  because  in  difl'erential  diagnosis  between 
the  latter  and  kidney-tumors,  they  exclude  the  latter.  These  peritoneal 
friction-sounds  are  sometimes  palpable  by  their  sound,  which  resembles 
crunching  of  snow. 

An  auscultatory  phenomenon  but  little  heeded  is  intestinal  splashing, 
which  is  to  be  distinguished  from  the  gurgling  sounds,  which  latter  are 
quite  insignificant. 

In  order  to  obtain  this  splashing  sound  I  recommend  indirect  suc- 
cussion  by  taking  hold  of  the  iliac  bones  and  shaking  to  and  fro.  In  the 
presence  of  marked  dilatation  of  intestinal  loops,  which  occur  only  with 
stenosis  and  paralytic  conditions  (peritonitis),  there  result  difl'use,  often 
rumbling,  splashing  sounds,  and  the  ear  can  often  approximately  deter- 
mine the  seat  of  their  origin. 

Particular  attention  should  be  given  to  unilateral  splashing  in  the 
flanks,  e.g.,  in  the  region  of  the  ascending  colon,  which  is  occasionally 
found  with  carcinomatous  diseases  of  this  portion  of  the  bowel.'- 

Sometimes  the  ascent  and  descent  of  the  diaphragm  produce  enough 
agitation,  leading  to  "inspiratory"  bowel  splashing  (Ca.  flex,  hepat.,  3). 

J/..  Percussion 

Its  significance,  in  the  cases  of  disease  here  under  consideration,  ex- 
hausts itself  in  the  demonstration  of  ascites.  The  percussion-note  tells 
us  nothing:  in  regard  to  the  situation  of  a  tumor  in  the  intestinal  wall, 
because  tumors  that  are  externally  adjacent  to  the  bowel-wall  or  such  as 
are  covered  by  the  intestine,  yield  identical  findings  on  percussion. 

Liver  dulness  is  often  greatly  diminished  on  account  of  existing 
meteorism. 

"  See  Ca.  ceci.,  1. 

"  Ca.  ceci,  1 ;  flex,  hepat.,  1 ;  recti,  6. 


CARCINOMA    OF    THE    LARGE    INTESTINE  117 

FECES   AND   STOMACH   CONTENTS 

Feces 

The  quality  of  the  bowel  evacuations  in  cancer  of  the  large  intestine 
varies  within  wide  limits  and  depends  upon  different  influences,  such  as 
the  scat  of  the  neoplasm,  ulceration,  accompanying  catarrh  of  the  large 
bowel,  etc. 

Dysenlevy-Like 

Carcinoma  of  the  rectum  and  of  the  sigmoid  flexure  more  than  others 
offer  findings  of  diagnostic  import.  Here  we  meet  with  stools  that  are 
"dysentery-like,"  i.e.,  composed  of  bloody  mucus  and  sparse  fecal  masses 
or  of  the  former  alone,  frequently  accompanied  by  tenesmus,  which  should 
always  be  the  occasion  for  a  careful  examination  of  the  lower  portions  of 
the  bowel.  They  may  be  provoked  by  cathartics.  If  we  are  dealing  with 
individuals  of  advanced  age,  there  are  usually  underlying,  deep-seated 
ulcerating  cancers  of  the  rectum. ^^  The  copious  evacuations  in  such  cases 
cannot,  for  apparent  reasons,  be  controlled  by  diet  or  astringents. 

It  is  with  these  deep-seated  neoplasms  more  than  others,  and  even  here 
not  often,  that  we  find  the  discharge  of  large  quantities  of  blood  which  is 
liquid  and  partly  coagulated  (Ca.  recti,  6,  10;  flex,  sigm.,  5). 

Knotty  and  Rihhon-Lil'e 

Naturally,  there  may  also  be  absent  copious  evacuations  with  deep- 
seated  cancers  of  the  large  intestine  and,  instead,  there  may  be  present 
most  obstinate  obstipation  with  the  discharge  of  marble-like  stools  (Ca. 
recti,  3).  This  last-mentioned  form  of  stool,  as  well  as  ribbon-like  stools, 
as  is  well  known,  has  nothing  to  do  with  stenosis  of  the  bowel.  Feces 
resembling  that  of  sheep  are  very  frequently  found  with  idiopathic  chronic 
obstipation ;  ribbon-like  stools  are  mostly  attributed  to  spasm  of  the 
sphincter. 

I  am  inclined  to  attribute  it  more  to  relations  between  the  closing  of 
the  sphincter  and  the  expulsive  forces,  since  this  shape  of  stool  is  also 
found  with  spasm  of  the  sphincter. 

IcJiorous 

In  the  case  of  the  neoplasms  situated  higher  up  in  the  bowel  (cecum, 
hepatic  and  splenic  flexures)  the  stools  are  indeed  never  well  formed, 
being  mostly  pulpy,  soft,  smeary,  but  in  no  way  are  they  characteristic. 
Their  macroscopic  appearance  affords  no  hint  of  blood,  except  such  small 
quantities  as  may  come  from  coexisting  hemorrhoids ;  chemical  analysis, 
however,  often  yields  constantly  positive  evidence  of  blood-coloring  mate- 
rial. Only  exceptionally  do  we  meet  with  fluid,  foamy  evacuations  with  a 
penetrating  stinking  odor  (Ca.  flex,  hepat.,  2). 

"  See  Ca.  flex,  sigm.,  5,  6 ;  flex,  hepat.,  4. 


118  TUMORS    OF    THE    ABDOMINAL    VISCERA 

The  reaction  of  the  stools  is,  as  a  rule,  decidedly  alkaline,  correspond- 
ing to  the  preponderance  of  processes  of  decomposition. 


Microscopy  of  the  Feces 

Microscopically,  the  following  findings  deserve  attention: 

1.  Bacterial  growths. 

2.  Alimentary  findings. 

3.  Cytological  findings. 

Ad  1.  As  gastric  carcinoma  gives  rise  to  the  presence  of  noteworthy 
vegetative  findings  (lactic-acid  bacilli,  sarcinae,  etc.),  so  we  also  expect 
analogous  findings  with  cancer  of  the  large  intestine.  Yet,  the  conditions 
here  are  far  more  complicated,  because  pre-existing  bacterial  growths  must 
be  taken  into  account. 

Though  specific  findings  may  be  absent,  a  review  of  the  fecal  vegeta- 
tion in  the  native  or  "Gram  preparation  ''  may  sometimes  afford  informa- 
tion which  puts  the  physical  and  chemical  conditions  underlying  normal 
intestinal  vegetation  into  an  altogether  different  light.  Thus,  I  remem- 
ber a  case  of  cancer  of  the  large  bowel  (Ca.  ceci,  4),  which  was  conspicu- 
ous for  the  large  number  of  very  motile  short  rod-shapes  which  crossed 
the  microscopic  field  in  all  directions.  Such  a  finding  is  decidedly  patho- 
logical. The  rod-shaped  bacteria  of  normal  feces  do  not  exhibit  any 
spontaneous  movements,  but  show  only  the  well-known  molecular  move- 
ment. 

In  other  cases  there  occur  spirochetes  in  large  numbers,  which  also 
are  foreign  to  the  normal  picture  of  the  stool.  I  can  also  recall  observa- 
tions in  which  the  stool  was  characterized  by  the  appearance  of  Gram- 
positive  cocci  in  large  quantities ;  in  fact,  they  were  present  in  such 
quantities  as  I  have  otherwise  observed  only  in  pernicious  anemias.  Lac- 
tic-acid bacilli,  also,  may  occasionally  occur  in  larger  quantities  (Ca. 
ceci,  2 ;  flex,  hepat.,  1 ). 

To  attach  proper  meaning  to  these  and  similar  findings  among  the 
symptoms  of  cancer  of  the  large  intestine,  is  a  matter  of  personal  experi- 
ence. Whoever  is  but  little  acquainted  with  vegetative  findings,  will  do 
better  to  leave  them  out  of  his  calculations.  The  expert  will  often  find 
them  valuable  aids. 

Alimentary  Findings 

Ad  2.  Carcinomatous  disease  of  the  large  bowel  is  attended  by  severe 
functional  disturbance  of  the  entire  digestive  tract. 

This  is  evidenced  by  the  frequent  finding  of  poorly  digested  muscle- 
fibres  which  can  often  be  found  in  large  quantities  and  which  show  well- 
preserved  transverse  striation.  Also  fat  digestion  may  be  considerably 
impaired,  as  I  remember  that,  in  cases  of  sanious  diarrheas  (Ca.  flex, 
hepat.,  2),  in  addition  to  fatty  acid,  I  also  found  neutral  fat  (pancreas 
intact,  no  icterus).  The  stools  contained  fat  with  a  paradoxical,  strongly 
alkaline  reaction ! 


CARCINOMA    OF    THE    LARGE    INTESTINE  119 

Cytological  Findings 

Ad  3.  Among  the  cellular  elements  I  would  call  attention  to  eosinophile 
cells,  which  are  not  infrequently  present,  especially  with  deep-seated  neo- 
plasms of  the  large  bowel,  though  not  indeed  in  such  vast  numbers  as  occa- 
sionally happens  in  amebic  dysentery. 

Gastric   Findings 

Chief  among  the  gastric  findings  is  the  frequent  persistence  of  HCl 
secretion  (Ca.  ceci,  4;  flex,  sigm.,  10). 

In  the  course  of  stenotic  conditions,  among  others  with  perforative 
peritonitis  (Ca.  flex,  sigm.,  9),  there  may  occur  "coffee-ground"  vomit- 
ing (Ca.  flex,  lien.,  1;  flex,  sigm.,  5),  but  in  these  cases  the  vomitus  does 
not  exhibit  the  vegetation  of  lactic-acid  bacilli,  so  peculiar  to  carcinoma 
of  the  stomach. 

If,  during  the  course  of  stenosis  attacks,  the  feces  are  prevented 
from  passing  for  a  long  time,  there  often  ensues  the  vomiting  of  yellow 
masses  containing  bilirubin,  in  which  colon  bacilli  turn  up  in  rapidly  in- 
creasing quantities,  as  also  Gram  positive  rod-shapes  and  cocci,  so  that 
we  finally  have  the  picture  of  intestinal  bacterial  growths.  These  bac- 
teriological findings  precede  fecal  vomiting  and  therefore  deserve  serious 
attention. 


ACCOMPANYING   SYMPTOMS   ON   THE    PART   OF 
INDIVIDUAL    ORGANS 

Urinary  Bladder 

In  so  far  as  carcinomas  of  the  cecum,  the  sigmoid  flexure,  or  the 
rectum  are  concerned,  symptoms  of  the  urinary  bladder  count  among  the 
not  infrequent  accompanying  symptoms.  Thus  pressure  of  the  tumor- 
masses,  distended  loops  of  intestines,  etc.,  upon  the  urinar}'  bladder  may 
produce  increased  desire  to  urinate ;  or  there  may  occur  the  entrance  of 
colon  bacilli  from  the  bowel  with  secondary  cj^stitis.  Then  we  often  have 
tenesmus  of  the  bladder  with  pains  radiating  into  the  penis.  The  tenes- 
mus may  become  so  violent,  that  incontinence  results  (carcinoma  flex, 
sigm.,  8).  Sometimes  there  is  also  a  disturbance  in  the  separate  voiding 
of  stool  and  urine,  so  that  with  urination  there  occurs  simultaneous  stool 
evacuation  (Ca.  flex,  sig.,  4;  recti,  12). 

Finally,  there  may  even  be  established  a  vesico-rectal  fistula  so  that 
feces  gain  entrance  into  the  urinary  bladder  (Ca.  flex.,  sigm.,  3;  recti, 
11).  In  these  cases  the  patients  refer  to  characteristic  gurgling  sounds, 
occurring  during  urination,  which  are  due  to  the  presence  of  intestinal 
gases  in  the  bladder.  Examination  of  the  urinary  sediment  reveals,  among 
other  things,  muscle  fibres  and  intestinal  bacteria ;  a  finding  most  charac- 
teristic of  these  are  the  yeast-like  clostrides  which  stain  blue  with  Lugol, 
since  their  occurrence  in  the  body  is  limited  to  the  bowel  exclusively.  Th*^ 
portions  of  urine  voided  last  contain  the  largest  proportion  of  feool 
matter. 


120  TUMORS    OF    THE    ABDOMINAL    VISCERA 

The  subjective  symptoms  in  sucli  cases  of  vesico-rectal  fistula  are 
sometimes  quite  confusing,  because  of  their  insignificance. 

These  and  similar  observations  emphasize  the  fact  that,  with  the 
presence  of  bladder  symptoms,  especially  in  advanced  age,  the  intestinal 
proximity  of  the  urinary  bladder  must  not  be  left  out  of  consideration. 

Varicocele 

Attention  must  also  be  called  to  the  occasional  occurrence  of  a  left- 
sided  varicocele,  with  radiating  sensations  into  the  left  testicle;  this  is 
most  frequently  found  with  carcinoma  of  the  rectum  and  sigmoid. 

Peritoneum 

Diffuse  metastasis  onto  the  peritoneum,  with  a  general  peritoneal  car- 
cinosis, does  not  belong  to  the  frequent  findings.  When  carcinoma  of 
the  large  intestine  is  accompanied  by  severe  ascites,  we  must,  in  the  first 
place,  think  of  hepatic  complications.  We  arc  dealing  cither  with  metas- 
tases in  the  liver,  or  with  the  not  rare  cirrhotic  complications  (Ca.  flex, 
hepat.,  4;  flex,  sigm.,  1,  9). 

Extensive  metastases  in  the  retroperitoneal  glands  may  lead  to  con- 
gestion of  chyle,  and  thus  to  the  occurrence  of  a  "milky"  ascites  (Ca. 
flex,  hepat.,  4). 

Liver 

Liver  metastases  are  most  frequently  found  with  cancer  of  the  rec- 
tum and  sigmoid,  the  enormous  enlargement  of  the  organ  in  these  cases 
often  standing  in  sharp  contrast  to  the  small  size  of  the  primar}"  focus. 
This  seems  to  be  almost  a  rule.  Large  secondary  cancers  mostly  issue 
from  a  small  cancerous  focus!  Accompanying  perihepatitis  may  lead  to 
very  extensive  radiations  of  pain  (Ca.  recti,  12).  Even  very  diffuse 
liver  metastases  lead  to  only  mild  subicteric  discoloration,  but  not  to  a 
pronounced  icterus.  If  icterus  does  occur,  it  may  under  certain  circum- 
stances again  disappear  (Ca.  recti,  4). 

Lymph    Glands 

Metastasis  into  the  external  lymph-glands  (inguinal,  supra-clavicu- 
lar axillary)  is  almost  never  observed.  Where  we  find  enlarged  glands, 
as,  for  instance,  in  observation  2  (Ca.  ceci),  it  will  be  well  to  think  of 
another  etiology,  e.g.,  tuberculosis. 

Sheletal  System 

Bone  metastases  also  are  quite  extraordinary.  Case  1  (Ca.  ceci) 
is  an  exception  in  this  respect.  Through  metastasis  into  the  cervical 
vertebra,  in  this  instance,  there  resulted  an  ascending  paralysis  of  the 
various  extremities.  In  this  very  exceptional  case,  metastases  occurred 
even  in  the  scalp,  which  in  the  beginning  surgeons  had  erroneously  looked 
upon  as  atheromas. 

Generally,  however,  carcinoma  of  the  large  intestine  docs  not  exhibit 
any  special  tendency  to  the  formation  of  metastases,  and  it  is  this  as 
well  as  its  good  accessibility  to  the  surgeon  that  renders  its  diagnosis  of 


CARCINOMA    OF    THE    LARGE    INTESTINE  121 

practical  iiiiportaiict'.  In  view  of  the  fact,  that  in  cases  of  cancer  of  the 
hirge  bowel,  the  intake  of  food  and  its  assimilation  do  not  suffer  for  a 
long  time,  especially  when  the  cancer  is  low  down,  and  since  we  are  often 
dealing  with  vigorous  individuals  who  have  always  enjoyed  the  best  health, 
there  can  be  little  wonder  that  the  general  state  of  nutrition  sometimes 
remains  good  for  a  time.  With  prolonged  duration  of  ulceration,  how- 
ever, there  results  also  in  these  cases  t^'pical  cancerous  cachexia,  often 
accompanied  by  extreme  pallor,  and  frequently  there  is  also  the  ten- 
dency to  moderate  edemas. 

Fever,  Night-Sweats 

Febrile  movements   (Ca.  ceci,  3,  -1;   recti,   13)    and  night-sweats   are 
frequent  accompanying  manifestations. 


COURSE,    DURATION    AND    TYPES 

A  fact,  recognition  of  which  is  important,  because  it  might  lead  to 
the  abandonment  of  a  suspicion  that  has  already  been  formed,  is  the 
oft  intermittent  and  remittent  course  of  the  clinical  manifestations. 

Thus,  for  several  days  there  may  be  present  stools  of  a  d^^senteric 
character,  which  are  succeeded  for  a  long  time  by  regular  bowel  move- 
ments and  general  well-being,  until  new  attacks  again  set  in  (Ca.  flex, 
sigm.,  5). 

With  improved  appetite  the  body-weight  may  become  considerably 
increased ;  thus  in-  one  case,  for  instance,  there  was  a  gain  in  weight  of 
14  kg  (Ca.  flex,  hepat.,  2). 

Obstinate  obstipation  may  be  followed  by  fairly  regular  bowel  move- 
ments. In  the  beginning,  after  their  first  appearance,  colics  may  be  ab- 
sent for  months. 

The  duration  of  that  stage  of  intestinal  cancer,  in  which  clinical 
symptoms  manifest  themselves,  seems  to  me  to  be  shorter  than  that  of  the 
average  gastric  cancer,  so  far  as  the  dates  can  be  determined  from  the 
patient's  history. 

I,  for  my  part,  consider  a  two-years'  duration  as  exceptionally  long. 
In  this  respect,  however,  there  is  a  great  divergence  of  opinions  among 
different  observers. ^^ 


SUSPICIOUS    FACTORS    AND    DIFFERENTIAL    DIAGNOSIS 

As  far  as  the  localization  of  the  neoplasm  in  the  bowel  is  concerned, 
there  are  certain  indications  that  frequently  come  into  the  foreground 
and  are  specially  adapted  to  guide  us  in  the  right  diagnostic  path.  Apart 
from  the  general  symptoms,"*^  tliey  will  here  be  summarized  in  groups. 

'"Thus   Kraske    (Samml.   klin.   Vortr.   Xeiie   Folge,   Nos.   183,   184.,   1897)    estimates 
the  average  duration  of  rectal  cancer  as  four  to  five  years. 
"  See  page  37. 


122  TUMORS    OF    THE    ABDOMINAL    VISCERA 

1.  Discharge  of  blood  and  mucus  accompanied  by  violent  tenesmus. 
Such  "dysentery-like"  stools  must  always  remind  one  of  the  possibility 
of  a  deep-seated  carcinoma  of  the  rectum  or  sigmoid  flexure.  One  should 
never  content  himself  with  the  mere  findings  of  hemorrhoids,  as  these 
frequently  are  only  an  accompanying  manifestation  of  deep-seated  car- 
cinoma. 

On  the  other  hand,  one  must  be  on  his  guard  in  making  the  diagnosis 
of  "dysentery"  (Ca.  flex,  sigm.,  5),  especially  when  dealing  with  a  spo- 
radic case.  Retrogression  of  the  symptoms  is  not  sufficient  ground  for 
exclusion  of  the  diagnosis  of  cancer. 

2.  Intestinal  colics  with  meteorism,  so-called  "wind  colics"  (Ca.  flex, 
hepat.,  1,  2;  recti,  3,  6,  9 ;  flex,  sigm.,  3).  Occurring  after  a  dietetic 
error  (the  use  of  gas-forming  foods,  etc.),  or  spontaneously,  they  fre- 
quently arc  the  clinical  debut  of  cancer  of  the  large  intestine.  In  the 
beginning  they  may  set  in  at  intervals  of  several  months,  but,  later,  they 
come  on  with  increasing  frequency.  They  deserve  the  most  serious  con- 
sideration, especially  where  we  are  dealing  with  individuals  of  "strong 
bowels,"  who  have  previously  never  had  any  bowel  complaints,  as  it  is 
just  from  this  class  that  a  large  percentage  of  patients  is  recruited. 
Prolonged  obstipation  seems  to  be  a  frequent  eliciting  factor,  so  much  so, 
that  one  could  often  speak  directly  of  obstipation  colics.  But,  since  it  is 
not  in  the  nature  of  "habitual"  obstipation  to  provoke  violent  colics, 
such  "obstipation  colics"  must,  among  other  things,  always  arouse  the 
suspicion  of  a  malignant  disease  of  the  large  intestine.  In  view  of  the 
fact  that  obstipation  also  accompanies  other  colics,  particularly  gall- 
stone and  renal  colics,  these  latter  processes  will  haVe  to  be  excluded 
after  a  very  careful  analysis  of  the  pains.  After  that  has  been  done,  in- 
testinal colics  will  have  to  be  diff"ercntially  diagnosed  from  the  more  fre- 
quent affections,  such  as  chronic  saturnismus,  intestinal  tuberculosis, 
appendicitis,  incarcerated  hernias,  etc. 

Especially  the  differentiation  from  appendicitis  may  occasionally  be 
difficult,  not  only  in  the  case  of  carcinoma  of  the  cecum  but  also  in  deep- 
seated  rectal  cancers,  in  which  cases  there  may  result  severe  distention 
and  sometimes  even  perforation  of  the  cecum  (Ca.  flex,  sigmoid,  1). 

On  the  other  hand  I  have  repeatedly  observed,  after  appendicitis  in 
older  individuals,  remarkably  firm  exudates  accompanied  with  very  slight 
febrile  movements  and  slight  tenderness  to  pressure,  in  which  cases  it 
was  only  the  fact  of  absolute  health  up  to  the  time  of  the  attack  and  the 
further  course  of  the  disease,  that  guarded  against  confusion  with  car- 
cinoma. 

The  diagnostic  difficulties  are  so  much  the  greater,  since  cancers  of 
the  large  intestine  may  lead  to  secondary  pericolitic  suppurations.'*' 

With  cancer  of  the  hepatic  flexure  (3)  there  is  sometimes  danger  of 
confusion  with  cholelithiasis.  Deep-seated  cancers  of  the  rectum  may 
also  lead  to  sensations  radiating  into  the  left  testicle  (Ca.  flex,  sigm., 
3),  which  might  lead  to  the  erroneous  diagnosis  of  urethral  colic. 

"  Tu-fjier,  Semaine  medicale,  1904.  No.  25. 


CARCINOMA    OF    THE    LARGE    INTESTINE  123 

3.  Unaccountable  obstipation  in  an  individual  without  previous  in- 
testinal complaints.  The  symptoms  of  obstipation  may  become  more  sig- 
nificant when  considered  with  reference  to  the  "bowel  individuality"  of 
the  patient.  Frequently  we  are  dealing  with  individuals  whose  intestinal 
function  was  always  perfectly  regulated  (Ca.  flex,  sigm.,  4;  recti,  5), 
"like  a  clock,"  the  patients  will  often  say ;  suddenly,  apparently  without 
cause,  stubborn  obstipation  sets  in !  In  such  cases,  we  are  compelled  to 
think  of  the  possibility  of  cancer  of  the  large  bowel.  Also  in  these  cases, 
as  has  already  been  emphasized  elsewhere,  deceptive  remissions  may  occur, 
the  bowel  movements  becoming  regular  for  a  long  time. 

The  paradoxical  combination  of  obstipation  with  occasional  violent 
tenesmus  and  incontinence  (Ca.  recti,  5)  must  seem  particularly  sus- 
picious. 

■i.   Acute  ileus. 

Whilst  the  occlusion  of  the  bowel  may  frequently  be  introduced  by 
the  above-mentioned  attacks  of  colic,  it  may  occasionally  also  occur  as 
the  first  symptom  in  the  midst  of  apparently  good  health.  Here  the  his- 
tory must  aim  at  finding  s^nnptoms  dating  farther  back,  which,  of  course, 
may  often  be  of  rather  inconsequential  nature,  and  besides  incarcerated 
hernias,  intestinal  tuberculosis,  etc.,  the  possibility  of  carcinoma  of  the 
large  intestine  will  have  to  be  considered. 

5.  Obscure  febrile  conditions  in  older  individuals,  though  accom- 
panied by  only  slight  abdominal  symptoms,  must  urge  us  to  think  of  the 
possibility  of  cancer  of  the  large  bowel,  since  these  cases  are  often  ac- 
companied by  chronic  febrile  conditions  with  irregular  rises  in  tempera- 
ture but  occasionally  also  with  chills  (Ca.  ceci,  3). 

6.  Tumor-masses   in   the   topographical   area   of   the   large   intestine. 
Definite  palpatory  findings   do  not,   of  course,  belong  to  the  early 

symptoms,  which  justifies  us  in  assigning  to  them  the  last  place  among 
the  factors  of  suspicion.  They  may  be  permanently  absent  when  we  are 
dealing  with  circular  stricturing  cancers,  %s  is  the  case  especially  in  the 
region  of  the  sigmoid  flexure.  In  these  cases  hard  and  impacted  sc^'^bala 
are  frequently  mistaken  for  tumors. 

Tuberculosis  of  the  Cecum 

At  the  cecum  it  is  the  tumor-forming  type  of  ileocecal  tuberculosis 
that  enters  into  differential  diagnostic  consideration ;  the  tumors  may  be 
extraordinarily  firm.  The  guiding  viewpoints  in  these  cases  are:  a  most 
careful  examination  of  the  pulmonary  apices,  determination  of  the  diazo 
reaction  in  the  urine,  and  demonstration  of  tubercle  bacilli  in  the  stool. 

Corset  Lobes 

One  must  be  cautious  not  to  mistake  corset  lobes  of  the  liver  which 
are  sometimes  observed  in  the  cecal  region  in  enteroptotic  women. 

Kidney  Tumors 

Tumors  belonging  to  the  ascending  and  descending  colon  not  seldom 
exhibit  slight  ballottement,  and  this  might  lead  one  to  think  of  kidney 
tumors   (Ca.  flex,  hepat.,  3).     Peritoneal  friction  over  the  tumor  would 


124^  TU:\10RS    OF    THE    ABDOMINAL    VISCERA 

speak  against  a  tumor  of  the  kidney.  If  belonging  to  the  bowel,  the  his- 
tory will  reveal  intestinal  symptoms,  and  there  will  also  be  the  objective 
demonstration  of  "occult"  intestinal  hemorrhages,  occasionally  it  might 
also  be  well  to  institute  a  dietetic  test.  With  solid  retroperitoneal  tu- 
mors, the  portions  of  bowel  overlying  them  anteriorly  can  be  rolled  to 
and  fro,  which  would  serve  as  a  further  distinguishing  criterion. 

Gastric  Carcinomas 

In  case  of  carcinoma  of  the  ascending  colon,  there  is  sometimes  diffi- 
culty in  deciding  whether  the  tumor  does  not  belong  to  the  stomach  (Ca. 
flex,  hepat.,  2).  Gastric  symptoms,  such  as  anorexia,  heartburn,  vomit- 
ing, etc.,  are  frequently  met  with.  Among  others,  protracted  diarrheas 
would  here  argue  much  more  in  favor  of  the  diagnosis  of  cancer  of  the 
intestine. 

Mistaken  diagnosis  seems  to  me  most  likely  to  occur  with  carcinoma 
situated  at  the  splenic  flexure  (carcinoma  Hex.  lienal,  2). 

In  regard  to  the  occurrence  of  "coffee-ground"  vomiting,  this  has 
already  been  discussed  in  another  place. 

Tumors  of  the   Gall-Bladder  and  Liver 

Tumors  of  the  hepatic  Hexure,  especially  when  adherent  to  the  liver 
and  leading  to  subicteric  discoloration  and  febrile  movements,  may  occa- 
sion confusion  with  tumors  of  the  gall-bladder  and  liver. 

Cylindrical  tumors  lying  transversely  in  the  middle  of  the  epigastrium 
almost  always  belong  to  the  pylorus ;  beginners  like  to  refer  these  to  the 
transverse  colon. 

Greatest  reserve  ought  to  be  maintained  with  respect  to  palpatory 
findings  in  the  region  of  the  sigmoid  flexure.  What  is  here  felt  from 
without  is  but  rarely  a  carcinomatous  tumor.  Even  when  a  cancer  is 
present,  that  which  is  felt  is  most  often  the  impacted  scybala  or  the  flex- 
ure itself  which  lias  become  hjpertrophicd  or  altered  by  chronic  inflam- 
mation. It  is  well  known  that  cancers  of  the  flexure  frequently  cannot 
be  palpated  because  they  are  ring-shaped  and  scirrhus. 

Cancer  of  the  rectum  naturally  is  most  apt  to  be  confused  with  ma- 
lignant processes  which  produce  stenosis  from  without,  thus  above  all 
certain  forms  of  gastric  cancer  with  metastasis  in  the  pouch  of  Douglas, 
occasionally  also  ovarian  cancers. 

Intactness  of  the  mucosa  overlying  the  tumor-masses  is  probably  an 
important  criterion,  in  connection  with  which  it  must  only  be  borne  in 
mind  that  also  cancers  of  the  flexure  high  up  can  be  palpated  through 
the  intact  mucosa  of  the  lower  portions  of  the  bowel. 

Even  with  sarcoma  of  the  rectum,  according  to  Kraske,''  there  is 
little  tendency  to  ulceration,  so  that  the  mucosa  may  be  found  intact. 

"  P.   Kraske,   Samnihing  klinischer   Vortrage.     New   Series,   Nos.   183,   184,  1897. 


Primary  and   Secondary   Cancer  of  the  Liver 

With  the  various  differently  situated  cancer-tumors  (gastro-intcs- 
tinal,  thyroid  gh\nd,  breasts,  etc.)  it  is  always  of  importance  to  deter- 
mine whether  metastasis  has  already  taken  place  in  the  liver-tissue,  posi- 
tive findings  being  a  strict  contraindication  for  radical  surgical  pro- 
cedure. 

On  the  other  hand,  no  therapeutic  or  prognostic  significance  attaches 
to  the  decision  whether  a  carcinomatous  alteration  in  the  liver  takes  its 
origin  from  the  liver-tissue  itself  or  is  carried  in  from  some  primary 
focus;  therefore,  it  seems  justifiable  to  me,  that  both  forms  be  clinically 
considered  in  common,  the  more  so,  since  the  assumption  of  a  primary 
cancer  of  the  liver  can  be  arrived  at  only  by  exclusion. 

The  diagnosis  of  cancer  of  the  large  glands  (liver,  pancreas)  is  ren- 
dered especially  difficult  by  the  fact  that,^  even  with  extensive  cancerous 
infiltration  of  these  organs,  recognizable  disturbances  in  function  are 
often  absent.  So,  for  instance,  in  carcinoma  of  the  liver,  in  the  primary 
as  well  as  secondary  forms,  a  distinct  icterus  does  not  occur  in  most 
instances. 

A  further  difficulty  lies  in  the  fact  that  pain  phenomena  mostly  occur 
first  at  a  time  when  the  peritoneal  covering  of  the  organ  becomes  in- 
flamed through  subperitoneally  located  cancer-masses.  If  the  cancerous 
proliferation  develops  from  central  portions  it  may,  through  lack  of  con- 
tact with  the  peritoneum,  easily  run  its  course  without  s3'mptoms.  This 
may  explain  why  precisely  primary  cancers  of  the  liver  are  frequently 
not  detected  until  the  last  stages  of  the  disease  have  set  in. 

EARLY    SYMPTOMS 

If,  from  the  beginning,  cancerous  nodules  develop  subperitoneall}", 
that  is,  in  the  peripheral  layers  of  the  liver-tissue — which  is  especially 
true  of  the  secondary  forms — it  is  possible  that  phenomena  of  pain  will 
be  among  the  first  symptoms.  They  will,  therefore,  deserve  serious  atten- 
tion when  there  is  thought  of  liver  metastases.  Reversal  of  this  rule  would 
not,  of  course,  obtain.  Even  very  extensive  cancerous  infiltrations  of  the 
liver  with  enormous  enlargement  of  the  organ  may  run  along  without 
spontaneous  or  artificially  evoked  pains  (1,  3),  and  it  is  often  surprising 
to  note  the  degree  of  adaptation  of  which  the  liver  is  capable. 

In  other  cases,  however,  diflfuse  or  circumscribed  exquisite  pain  can 
be  elicited  over  the  organ  in  the  epigastrium  by  pressure  or  by  the  more 
readily  regulated  percussion  stroke.     With  this  there  may  occur — though 

125 


126  TUMORS    OF    THE    ABDOMINAL    VISCERA 

seldom — radiations   into   the   right  shoulder  and   shoulder-blade    (7),   as 
they  sometimes  also  occur  spontaneously. 

INIovements  such  as  stooping,  pulling  off  the  shoes,  etc,  which  bring 
about  pressure  upon  the  organ,  also  the  sitting  attitude,  are  painful. 
Tenderness  to  pressure  is  frequently  found  in  the  region  of  the  right  loin. 
Special  attention  is  due  to  tenderness  localized  in  certain  areas  of  the 
liver  surface.  This  would  point  to  some  localized  process  distributed  in 
the  liver,  in  connection  with  which,  aside  from  gummata  and  abscesses, 
there  especially  enters  into  consideration  the  existence  of  carcinoma. 

Here,  however,  it  must  be  borne  in  mind  that  also  with  diffuse  altera- 
tions of  the  organ  (e.g.,  congested  liver),  the  greatest  tenderness  on  per- 
cussion is  met  with  mostly  in  the  linea  alba. 

Intumescence  of  the  organ  leads  to  exceedingly  unpleasant  sensations 
of  pressure  and  fulness  in  the  epigastrium,  which  frequently  last  for  a 
long  time,  frequently  also  become  exacerbated,  especially  after  meals, 
and  by  their  increase  and  decrease  occasionally  resemble  attacks  of  colic. 

In  accordance  with  their  peritonitic  character,  perihepatic  compli- 
cations may  lead  to  the  severest  paroxysms  of  pain  (Sek.  Ca.  hepat.,  1), 
which,  quite  analogous  to  pleuritic  pains,  are  characterized  by  "stab- 
bing sensations." 

If  the  entire  peritoneal  covering  of  the  liver  is  acutely  inflamed,  any 
change  in  position  may  become  exceedingly  painful,  and,  as  in  acute  peri- 
tonitis, the  patients  are  immobilized  and  compelled  to  remain  in  one 
position. 

Medullary  gastric  cancers  seem  to  be  the  most  frequent  to  give  rise 
to  this  "forme  douloureuse"  of  secondary  cancer  of  the  liver;  it  may  be 
that  the  pronounced  ulceration  favors  the  importation  of  the  excitants 
of  inflammation. 

In  this  way  wc  may  get  pictures  of  disease  which  make  us  think  of 
some  acute  infectious  process  in  the  liver  (liver  abscess,  cholangitis,  lues, 
etc.),  rather  than  carcinoma,  pain  being  the  most  prominent  symptom. 

This  form  of  secondary  carcinoma  of  the  liver  in  which  the  phenomena 
of  pain  are  the  controlling  feature,  is  among  the  rarest  exceptions.  With 
primary  cancer  of  the  liver  it  is  observed  still  more  rarely.  Though  of 
secondary  importance,  the  painful  phenomena  due  to  perihepatic  condi- 
tions often  become  very  noticeable. 

Similar  to  pleuritic  pains,  they  depend  partly  upon  the  body  position, 
and  occasionally  set  in  very  acutely  (Prim.  Ca.  hepat.,  2)  ;  change  of  po- 
sition, coughing,  etc.,  frequently  provoke  exacerbations. 

They  are  usually  localized  on  the  right  side  under  the  costal  arch,  but 
occasionally  are  also  noticed  on  the  left  side  or  extend  in  girdle-like 
fashion  above  the  umbilicus  toward  the  back;  in  rare  cases  they  radiate 
from  the  epigastrium  into  the  right  and  sometimes  also  into  the  left 
shoulder. 

Whilst  carcinoma  of  the  gall-bladder  and  biliary  passages,  discussed 
elsewhere,  leads,  in  the  majority  of  cases,  to  icterus,  this  does  not  obtain 
in  the  primary  and  secondary  cancers  of  the  liver  here  under  consid- 
cration. 


CANCER    OF    THE    LIVER  127 

Absence   of  Icterus 

The  absence  of  pronounced  icterus  may  here  be  put  clown  as  a  rule 
(a  rule  with  exceptions). 

Bearing'  in  mind  that  primary  carcinoma  may  remain  locali/X'd  as  a 
focus  and  that  metastatic  cancer-nodules  often  are  scattered  in  the  liver- 
tissue,  this  rule  will  excite  but  little  wonder. 

The  absence  of  icterus  is  often  surprising  in  cases. where  the  liver, 
in  toto,  has  been  replaced  by  cancer-tissues.  Why  does  compression  of 
the  bile-ducts  and  secondary  icterus  not  occur? 

Compression  of  the  bile-ducts  probably  does  occur;  if,  in  spite  of 
this,  icterus  is  ^ibsent,  it'  may  be  due  to  two  factors : 

1.  The  channels  of  resorption  (lymph  and  blood  vessels)  may  be 
compressed. 

2.  The  production  of  bilirubin  may  be  greatly  diminished. 

A  sign  indicating  biliary  congestion  far  more  frequently  than  a  dis- 
tinctly jaundiced  skin,  are  the  light  stools  and  dark  urine  containing 
abundant  urobilinogen,  and  in  regard  to  the  significance  of  Ehrlich's 
aldehyde  reaction  we  must  refer  to  what  has  been  previously  said  of  it.'^ 


PHYSICAL  EXAMINATION  OF  THE  LIVER 

Collateral   Portal   Circulation 

Notw^ithstanding  the  acute  course  of  cancer  of  the  liver,  there  may 
occasionally  occur — as  in  benign  processes  accompanied  by  compression 
of  the  portal  vein — the  development  of  external  collateral  veins,  the  rec- 
ognition of  which  is  rated  among  the  most  important  and  most  signifi- 
cant findings  on  inspection. 

Coughing  or  pressure  will  bring  them  into  greater  prominence.  They 
extend  in  an  upward  direction,  mostly  in  the  middle  of  the  epigastrium 
(Prim.  Ca.,  1,  2),  over  the  lower  part  of  the  sternum,  or  they  cross  the 
right  costal  arch. 

It  has  been  tried  to  interpret  this  finding  of  collateral  veins  in  pri- 
mary cancer  of  the  liver  as  evidence  of  a  pre-existing  chronic  cirrhotic 
process ;  however,  secondary  cancerous  infiltrations  of  the  liver  also  are 
accompanied  by  analogous  formation  of  collateral  veins  without  any 
cirrhotic  disease,  which  rules  out  the  above  assumption. 

The  determination  of  a  collateral  portal  circulation  is  of  particular 
diagnostic  significance,  especially  in  those  cases  where  the  carcinomatous 
process  is  accompanied  by  ascites  or  where  the  enlargement  of  the  liver 
is  very  moderate,  thus  in  both  cases  yielding  unsatisfactor}-  findings  on 
palpation. 

"Soft"  Hepatic  Cancer 

With  reference  to  the  four  cardinal  points  of  examination  by  pal- 
pation, namely,  size,  shape,  surface  and  consistence,  it  must  be  empha- 
sized that — though  indeed  very  rarely — the  consistence  of  the  portions 

"See  page  33. 


128  TUMORS    OF    THE    ABDOMINAL    VISCERA 

infiltrated  with  cancer,  which,  as  a  rule,  distinguish  themselves  by  their 
especial  hardness  (board-like),  may  also  be  more  or  less  soft  (Prim. 
Ca.,  5).  With  secondary  cancer  of  the  liver,  this,  for  instance,  is  true 
of  primary  foci  in  the  testicle  or  in  the  thyroid  gland. 

Liver   Surface 

In  order  to  exactly  palpate  the  surface  of  the  liver,  it  is  highl}^  com- 
mendable to  make  the  examination  with  lateral  decubitus  (left-sided  po- 
sition for  the  right  lobe  and  vice  versa),  at  the  same  time  making  an 
effort  to  reach  as  far  as  possible  upward  under  the  costal  arch  and  the 
xiphoid  process,  which  is  best  accomplished  with  forced  diaphragmatic 
breathing.^'' 

The  finding  of  nodular  protuberances  will  call  mostly  for  differential 
diagnosis  from  gummata. 

With  a  smooth  surface  it  would  have  to  be  determined  whether  the 
increase  in  consistence  is  diffusely  even  or  limited  to  a  certain  area  of 
the  liver. 

Here  the  occasional  presence  of  "corset  lobes"  ^'^^  would  have  to  be 
ruled  out. 

Border  of  the  Liver 

In  ascertaining  the  location  of  the  hepatic  border,  which  is  particu- 
larly adapted  for  determining  the  consistence  of  the  liver,  care  must 
also  be  had  not  to  mistake  a  "corset  groove"  for  the  border.  Also,  the 
lower  border  of  a  cancerously  infiltrated  ligamentum  gastro-colicum 
might  be  mistaken  for  the  border  of  the  liver. 

A  rapid  increase  in  the  size  of  the  organ  counts  among  the  most  im- 
portant findings,  and  it  may  be  necessary  to  note  the  location  of  the 
lower  border  of  the  liver  by  one  or  more  marks. ^^'  ^- 

Pain  Phenomena 

Palpation  of  the  organ  ought  always  to  include  examination  for  pain- 
ful phenomena  that  can  be  elicited  by  various  mechanical  means,  such  as 
percussion,  change  in  position,  stooping,  etc. 

Aitsc^dtation 
Systolic   Murmurs 

Auscultation  in  some  cases  affords  evidence  for  assuming  a  compres- 
sion of  the  hepatic  arter}^  or  its  branches.  In  this  manner  we  must  in- 
terpret systolic  murmurs  (Prim.  Ca.,  1,6)  in  so  far  as  they  can  be  heard 
over  the  liver,  especially  in  the  region  of  the  right  lobe  and  not  too  near 
the  median  line.  Their  localization  seems  to  stand  in  intimate  relation 
with  the  spread  of  carcinomatous  infiltration  in  the  liver-tissue. 

According  to  our  own  observation,  they  reach  their  greatest  inten- 
sity toward  the  end  of  expiration.  Epigastric  systolic  murmurs  occur- 
ring near  the  median  line,  even  when   audible  over  the  liver,  are  much 

■^  See  page  3. 

'"  See  page  10. 

*",  ^-  Best  done  by  producing  a  linear  scratch  mark  with  a  needle. 


CANCER    OF    THE    EI\  EK  129 

more  difficult  of  interpretation  as  to  their  origin.  Here  there  is  a  pos- 
sibility of  their  originatinf;-  in  the  abdominal  aorta.  Tviuiors  lying  exter- 
nal to  the  liver  (pancreas,  stomach,  glands,  etc.)  may  cause  more  or 
less  compression  of  the  aorta,  and  in  and  of  themselves  or  through 
atheroma  of  the  vessel  give  rise  to  systolic  murmurs. 

Combined  examinations  Avill  frequently  disclose  the  fact  that  the 
systolic  murmurs  just  referred  to  become  weaker  and  finally  disappear. 
In  such  cases  the  assumption  is  close  to  hand  that  the  compression  af- 
fected smaller  arterial  trunks  and  that,  through  progressive  cancer  pro- 
liferation, a  stenosis  was  succeeded  by  complete  occlusion  of  the  blood- 
vessels, thus  bringing  about  a  cessation  of  the  murmurs. 

There  is  no  relation  between  the  spread  of  the  malignant  process  in 
the  liver  and  the  occurrence  of  these  murmurs.  It  seems  to  be  simph'  a 
matter  of  accident,  because  often  very  diffuse  neoplasmatic  infiltrations 
of  the  liver  run  along  without  murmurs,  whilst  circumscribed  areas,  on 
the  other  hand,  may  occasion  loud  murmurs. 

Perihepatic  Friction 

Auscultation  may  offer  elucidation  in  still  another  direction:  through 
the  finding  of  perihepatic  friction-sounds,  sometimes  recognized  on  pal- 
pation as  "snow  crepitation,"  it  may  point  to  a  local  focus  in  the  liver, 
thus  from  the  start  preponderatingly  narrowing  down  the  differential 
diagnostic  field  to  carcinoma,  lues  and  cholangitic  abscess  formation. 

ACCOMPANYING    SYMPTOMS    FROM    OTHER    ORGANS  «^ 

Gastro-In  testinal 

It  deserves  to  be  emphasized  that  gastro-intestinal  disturbances  may 
be  absent  in  primary  cancer  of  the  liver  until  the  last  stages  of  the  dis- 
ease (1,  2,  5). 

In  other  cases,  besides  the  occurrence  of  obstipation,  there  may  set 
in  early  anorexia  for  meat  and  meat  intolerance,  the  patient  complaining 
of  an  uncomfortable  sensation  of  pressure  in  the  epigastrium  after  the 
ingestion  of  food  (3). 

Accordingly,  the  chemical  findings  of  the  gastric  contents  will  vai'^', 
showing  perfectly  normal  conditions  of  secretion  (3)  or  a  cachectic 
aclilorh3'dria  (2). 

Terminally,  under  the  influence  of  increasing  portal  congestion,  there 
may  occur  "coffee-ground"  vomiting  and  melena  (T). 

Ascites 

Ascites  is  an  inconstant  symptom  ;  it  seems  to  occur  more  often  with 
moderate  enlargement  of  the  liver  than  with  great  intumescence,  which 
might  occasionally  have  some  connection  with  pre-existent  cirrhotic 
processes.  Particular  attention  should  always  be  given  to  a  hemorrhagic 
or  "milky"  character  of  the  ascites. 

*^  Only  the  primary  tumor  formations  of  the  liver  will  here  be  taken  into  con- 
sideration. 


130 


TUMORS    OF    THE    ABDOMINAL    VISCERA 


Spleen 

Great  enlargement  of  the  spleen,  so  that  the  organ  extends  below  the 
costal  arch,  does  not  seem  to  be  of  frequent  occurrence  in  connection  with 
primary  cancer  of  the  liver ;  swellings  of  lesser  degree  are  sufficiently  ex- 
plained by  the  oft  coexisting  portal  congestion. 

Leucocytes 

The  blood  may   show   moderate   increase   of  leucocytes   rather   than 
leucopenia,  a  fact  which  would  enter  into  consideration  at  times  in  the 
differential  diagnosis  from  the  cirrhosis  of  Laennec. 
Melanin 

In  respective  cases,  besides  the  aldehyde  reaction,  the  urine  would 
also  have  to  be  watched  for  melanin  (Prim.  Ca.,  7). 


SUSPICIOUS    FACTORS    AND    DIFFERENTIAL    DIAGNOSIS 

The  realm  of  differential  diagnosis  varies,  among  others,  according 
to  the  anatomical  distribution  and  form  of  the  cancerous  infiltration  of 
the  liver. 

Cirrhosis  of  Laennec  and  Fatty  Liver 

If  the  same  is  diffuse,  extending  over  both  lobes  and  not  accompanied 
by  nodular  protuberances  on  the  surface,  it  affords  a  palpatory  finding, 
which,  providing  the  enlargement  of  the  organ  remains  within  moderate 
limits,  leads  one  to  think  of  a  cirrhosis,  and,  since  icterus  is  mostl}'  ab- 
sent, particularly  a  cirrhosis  of  Laennec  (first  stage),  the  fatty  liver  of 
drinkers  sometimes  also  feels  very  firm,  and  may  thus  enter  into  the 
differential  diagnosis. 

Some  of  the  more  important  differential  diagnostic  points  will  here 
be  given  brief  review : 


Diffuse  Carcinoma.  Infiltration 
with  Smooth  Surface  without 
Icterus. 

Cachexia,  progressive  loss  of 
strength  and  enlargement  of 
liver,  pains,  perihepatic  fric- 
tion. 

Systolic  vascular  murmurs. 


Ascites  frequent,  at  times  becoming 
chylous  or  hemorrhagic. 

Liver  hard,  like  a  board. 

Moderate  leucocytosis. 

Occult  bowel  hemorrhage  (in  pri- 
mary gastro-intestinal  cancer). 

Often  after  the  60th  year  of  life. 


Cirrhosis  of  Laennec  {First  Stage), 
at  Times  Fatty  Liver. 

Appearance     good,     condition     re- 
mains stationar}' ;  no  pain. 


Auscultation  mostly  negative  or 
venous  hums,  after  the  type  of 
the  "Bruit  de  diable." 

Ascites  mostly  absent  or  serous. 

Consistence  less  firm. 
Leucopenia. 


Mostlv  before  the  60th  A'ear  of  life. 


CANCER    OF    THE    LIVER 


131 


It  must  be  mentioned,  however,  that  any  one  of  these  distinguishing 
marks  may  be  absent. 

Thus,  especially  in  so  far  as  primary  neoplasms  of  the  liver  are  con- 
cerned, cachectic  appearance  may  be  absent  even  with  enormous  swell- 
ing of  the  liver  (Prim.  Ca.,  7)  ;  cancerous  disease  may,  though  it  is  rare 
with  diffuse  infiltration,  run  its  course  without  pain,  the  consistence  may 
be  soft  or  at  least  appear  only  tensely  elastic,  so  that  in  the  latter  case 
there  may  arise  the  suspicion  of  a  cyst.  This  is  true  not  onl}-  of  pri- 
mary cancer  of  the  liver,  but  also  of  metastatic  infiltration,  especially 
when  the  primary  focus  consists  of  a  soft  tumor-mass  (testicle,  adrenal, 
thyroid,  etc.).  Esophageal  varices,  hemorrhoids  may  also  give  rise  to 
bowel  hemorrhages  in  connection  with  the  cirrhoses  of  Laemiec,  and  it 
must  be  borne  in  mind  that  gastro-intestinal  cancers  may  occasionally 
develop  in  individuals  afflicted  with  cirrhosis,  the  congestion  existing  in 
the  portal  system  perhaps  inducing  a  sort  of  predisposition.  Ulcers  of 
the  stomach  may  also  develop  in  connection  with  such  congestion.  All 
this  may,  with  cirrhosis,  lead  to  a  positive  blood-test  in  the  feces. 

Amyloidosis 

Where  we  are  dealing  with  a  cavernous  tuberculosis,  chronic  suppu- 
rative processes,  etc.,  a  diffusely  enlarged  hard  liver,  even  when  very 
voluminous,  can  hardly  be  interpreted  in  any  other  way  than  as  an  amy- 
loidosis. It  might,  however,  be  mistaken  for  a  carcinomatous  process 
where  the  cause  of  the  amyloidosis  is  rather  latent  (e.g.,  contracted  kid- 
ney, tubercular  intestinal  ulcers,  etc.). 

Biliary  Cirrhosis 

Those  generally  rare  cases  of  primary  or  secondary  cancer  of  the 
liver  ^^  which  are  accompanied  by  diffuse  enlargement  of  the  organ,  a 
smooth  surface  and  icterus,  will,  among  benign  diseases,  have  to  be  dif- 
ferentiated especially  from  biliary  cirrhosis. 


Increased.   Carcinoma,    Infiltration 
xclth  Smooth  Surface;  zcith  Icterus. 

Acute  course. 

Often  after  the  60th  year  of  life. 

Systolic  vascular  murmurs  over  the 
liver. 

Ascites  frequent. 

Occult  bowel  hemorrhages  in  pri- 
mary cancer  of  the  esophagus, 
stomach  or  bowel. 

Spleen  extending  to  the  costal  arch 
or  small. 

Enlargement  of  the  liver  progres- 
sive. 


Biliary  Cirrhosis. 

Chronic     course,     with     epigastric 

complaints   dating   far  back. 
Seldom  after  the  60th  year  of  life. 


Ascites  very  rare. 


Spleen  often  extending  consider- 
ably beyond   the   costal   arch. 

Plemeralopia   frequent. 

Enlargement  of  the  liver  station- 
ary. 


"  In  regard  to  carcinoma  of  the  gall-bladder,  see  page  133. 


132  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Where  a  localized  alteration  of  the  liver  with  distinct  protuberances 
on  the  surface  is  demonstrable,  the  field  of  differential  diagnosis  is  a  com- 
paratively narrow  one. 

Hepatic  Gumma 

If  the  alteration  affects  the  left  lobe  of  the  liver,  and  there  is  no  pro- 
nounced icterus,  the  possibility  of  a  gummatous  process  especiall}'  will 
have  to  be  reckoned  with  and  iodine  therapy  instituted.  Other  tertiary 
manifestations  of  lues  (bone  and  dermal  scars,  defects  in  the  nasal  sep- 
tum, the  gums,  choroiditis,  etc.)  should  always  be  looked  for;  the  Was- 
sermann  reaction  in  these  cases  is  almost  always  strongl}'^  positive. ^^ 
Those  cases  of  syphilis  of  the  liver  are  most  apt  to  lead  to  confusion 
which  exceptionally  run  their  course  accompanied  bj^  icterus  and  ascites 
and  severe  edemas,  especially  when  occurring  at  an  advanced  age. 

Unilocular  echinococcus  cysts  will  be  mistaken  extremely  seldom  be- 
cause cachexia  is  absent,  their  consistence  is  more  elastic,  and  subjective 
epigastric  symptoms  (sensation  of  pressure,  etc.)  often  date  far  back; 
it  is  only  when  the  disease  leads  to  severe  icterus — which  is  extremely 
rare  in  connection  with  unilocular  echinococcus  cysts — that  there  is  dan- 
ger of  erroneously  assuming  a  malignant  process  of  the  liver. 

Multilocular  echinococcus  cysts  might  offer  the  most  serious  difficulty 
because  the  syndrome  of  symptoms  confronting  us  here  may  be  of  a  de- 
cidedly malignant  complexion,  thus  exceedingly  firm  consistence  (mostly 
in  the  right  lobe  of  the  liver),  uneven  contour,  ascites,  icterus. 

As  compared  to  Bavaria,  Switzerland  and  Wiirtemberg,  Austria  con- 
tributes only  a  small  percentage  of  this  disease. 

Pleuritis 

The  perihepatic  pains  and  the  fact  that  they  are  influenced  by  breath- 
ing, coughing,  etc.,  may,  at  least  in  the  initial  stages  of  cancer  of  the 
liver,  be  mistaken  for  pleuritic  processes. 

Having  made  certain  the  diagnosis  of  a  carcinomatous  infiltration  of 
the  liver,  the  further  question  as  to  its  primarj'  or  secondary  nature  is  of 
purely  theoretical  interest. 

The  following,  among  others,  are  probable  grounds  for  assuming  a 
primary  cancer  of  the  liver : 

1.  Exclusion  of  primary  foci  situated  outside  of  the  liver,  in  which 
connection  such  rare  localities  as  lungs,  breasts,  testicles,  thyroid  and 
suprarenal  glands  would  have  to  be  taken  into  consideration.  Constantly 
negative  blood  findings  in  the  stool  will  render  cancer  of  the  esophagus, 
stomach  or  intestine  improbable. 

2.  Decided  swelling  of  the  spleen.  This  deserves  attention  in  so  far 
as  it  may  be  a  symptom  of  a  synchronously  existing  cirrhosis. 

3.  Very  youthful  age.  Statistics  show  that  primary  cancer  of  the 
liver  attacks  young  people  with  relative  frequency. 

4.  Severe  icterus  renders  a  primary  cancer  of  the  liver  highly  im- 
probable. 

*'i?.  Bauer,  Lues  iind  innere  Medizin.     Franz  Deuticke,  1910. 


Carcinoma  of  the  Gall-Bladder 


EARLY    SYMPTOiAIS 

On  comparing  the  functions  of  the  gall-bladder  to  tliose  of  other  or- 
gans, the  stomach,  for  instance,  in  which  latter  case  there  are  also  pres- 
ent other  sources  of  irritation,  we  find  that  conditions  in  the  former  organ 
are  far  more  simple,  its  activity  being  restricted  mainly  to  the  reception 
and  forwarding  of  the  .secretion  furnished  by  the  liver-cells.  Accordingly, 
one  might  expect  that  the  gall-bladder  would  be  the  last  among  the  organs 
likely  to  become  the  seat  of  cancer,  were  it  not  for  the  fact  that  occasion- 
ally it  has  to  suffer  grave  mechanical  injuries  from  concretions. 

Since  functional  disturbances  of  the  gall-bladder  have  much  less  op- 
portunity of  coming  to  the  surface  either  in  a  subjective  or  objective 
way,  than  is  the  case  in  such  organs  as  the  stomach,  it  cannot  be  won- 
dered at  that  the  first  symptoms  of  cancer  of  the  gall-bladder,  at  least  as 
far  as  the  anamnesis  discloses  them,  appear  at  a  comparatively  late  date 
and  often  only  a  few  months  before  death. 

In  the  majority  of  cases  the  first  symptoms  are  those  of  pain,  and  the 
correct  interpretation  of  these  painful  phenomena  counts  among  the  pri- 
mary requisites  for  an  early  diagnosis. 

Phenomena  of  Pain 

The  beginning  of  cancer  of  the  gall-bladder  consists  in  anatomical 
changes  of  the  organ  itself,  such  as  hardening  (tumefaction)  with  in- 
crease of  intravesical  pressure,  cholecystitis,  etc.,  or  it  may  be  perihepa- 
titis of  a  portion  of  the  liver,  which  is  adjacent  to  or  continuous  with 
the  gall-bladder. 

The  symptoms  of  pain  can  be  classified  in  two  groups. 

a.  Those  without  colic. 

These  are  frequently  stabbing  or  oppressive  pains  restricted  to  the 
gall-bladder,  which  are  mostly  dependent  upon  mechanical  causes  and 
frequently  appear  in  the  sitting  or  stooping  attitude,  whereas  they  are 
felt  but  little  or  not  at  all  in  the  erect  position,  i.e.,  standing  up. 

Rapid  walking,  coughing,  sneezing  and  lying  on  the  right  side  cause 

exacerbation  of  the  painful  symptoms,  hence  the  danger  of  confounding 

them  with  pleuritic  pain.     As  in  pleurisy,  it  is  found  that  lying  on  the 

healthy   side   is   intolerable   and   causes   the   sensation   of  pain   travelling 

from  right  to  left  in  the  painful  area  (3).     The  region  of  the  gall-bladder 

is  often  tender.     Pains  in  the  back  are  also  observable  and  the}'  radiate 

to   the   front   in   girdle   fashion,   sometimes   being  more   localized   on   the 

right  side.     At  the  same  time  there  may  be  tenderness  over  the  spinal 

column  in  the  interscapular  region. 

133 


134  TUMORS    OF    THE    ABDOMINAL    VISCERA 

If  the  liver  capsule  becomes  inflamed,  either  diffuse  or  circumscribed, 
as  a  result  of  cholangitic  complication,  such  as  abscess,  etc.,  the  organ 
becomes  tender  and  displacement  of  it,  such  as  occurs  during  breathing, 
change  of  position,  etc.,  proves  very  painful  (7)  ;  likewise  pain  is  elicited 
by  percussion  over  the  linea  alba,  where  the  organ,  by  simultaneous  sepa- 
ration of  the  recti,  is  found  most  immediately.  Stasis  of  bile  or  can- 
cerous infiltration  may  render  the  liver  tender  to  touch  and  percussion. 

b.   Colicky  symptoms. 

Just  as  the  presence  of  concretion  in  the  gall-bladder  is  looked  upon 
as  the  primary  cause  of  cancer  in  the  organ,  so  also,  conversel}^  it  is 
found  that  the  development  of  cancer  in  the  gall-bladder  gives  rise  to 
gall-stone  complaints  in  so  far  as  it  provokes  gall-stone  colic.  Often  the 
gall-stone  disease  remains  latent  up  to  this  time  and  the  developing  can- 
cer provokes  the  first  attack. 

Secondary  cholecystitis,  together  with  interference  in  the  flow  of  bile, 
may  be  considered  last  in  causing  attacks.  There  is,  therefore,  sudden 
and  severe  colic,  localized  in  the  epigastrium  or  in  the  region  where  the 
gall-bladder  may  be,  the  pains  radiating  into  the  loins  and  upward  into 
the  right  shoulder.  Percussion  of  the  liver  in  the  linea  alba  and  striking 
of  the  right  loin  with  the  fist  are  most  often  painful.  L3'ing  on  the  side 
is  barely  tolerated. 

Accompanying  symptoms :  vomiting  of  bile,  chills. 

Sometimes  the  painful  attacks  are  of  an  abortive  type,  but  by  their 
nocturnal  appearance  betray  their  colicky  nature.  Whilst  in  uncompli- 
cated gall-stone  colic  we  find  jaundice,  if  it  occurs  at  all,  making  its  ap- 
pearance within  a  few  succeeding  days,  we  find  with  complicating  gall- 
bladder cancer  that  stasis  of  bile  shows  up  several  weeks  later. 

In  uncomplicated  cholelithiasis  the  incident  anorexia  passes  away 
with  the  attack,  whereas  in  cases  complicated  with  cancer  the  anorexia 
becomes  more  permanent. 

Bile  Stasis 

As  the  evacuation  of  bile  can  go  on  even  without  a  gall-bladder,  as- 
happens  after  resection,  it  is  obvious  that  jaundice  may  be  permanently 
absent,**^  occur  very  late,  or  show  itself  in  the  last  phases  of  the  disease 
even  when  there  is  a  diffuse  carcinomatous  infiltration  of  the  wall  of  the 
gall-bladder.^^  This  is  especially  true  in  the  scirrhus  forms  of  gall- 
bladder cancer,  in  which  cases  there  is  considerable  shrinkage  of  the 
organ,  eventually  leading  to  stenosis  of  the  pylorus  or  the  hepatic  flexure 
of  the  colon. 

In  the  matter  of  an  early  diagnosis,  then,  not  much  significance  can 
be  attached  to  the  presence  of  a  decided  jaundiced  skin  or  discoloration 
of  the  mucous  membranes  or  the  demonstration  of  bilirubin  in  the  urine. 

More  important,  however,  because  appearing  earlier,  is  the  demonstra- 
tion of  increasing  quantities  of  urobilinogen  in  the  urine.     For  this  test 

'^Nos.  10,  11,  12,  13,  11,  17, 
"  Nos.  2,  7,  19,  21. 


CARCINOMA    OF    THE    GALL-BLADDER  135 

I  recommend  solely  Ehrlich's  aldehyde  reaction,  as  it  cannot  be  sur- 
passed in  simplicity. *^^ 

Negative  reactions  in  the  urine  should  not  be  used  for  diagnosis. 
Constantly  positive  findings  will  always  call  careful  attention  to  \\n-  liver, 
as  they  generally  coincide  with  mild  grades  of  biliary  stasis. 

The  reaction,  like  albumin  and  sugar  tests,  is  of  sufficient  importance 
to  become  a  routine  test  with  all  physicians.  In  obscure  abdominal  cases 
I  consider  the  neglect  of  the  examination  for  urobilin  a  great  mistake. 

Of  greatest  importance  is  the  failure  of  the  reaction  in  alcoholic  ex- 
tract of  stool  with  existing  jaundice,  since  this  is  a  positive  indication  of 
a  complete  obstruction  of  bile. 

If  in  a  case  of  cancer  of  the  gall-bladder  there  be  stasis  of  bile,  caus- 
ing urobilinogenuria  and  finally  the  elimination  of  bilirubin  in  the  urine 
and  jaundice,  then  we  may  consider  several  possibilities. 

a.  The  cancer  in  the  continuous  course  reaches  the  ductus  choledochus 
and  occludes  it.  In  this  way  there  occur  the  most  intensive  forms  of 
jaundice,  the  so-called  "Schwarzsucht."  These  are  cases  in  which  the 
urobilinogen  disappears  entirely  from  the  feces;  the  jaundice  becomes 
stationary  and  rarely  subject  to  change. 

b.  The  jaundice  depends  partly  or  entirely  upon  cholangitic  com- 
plications. Accordingly,  the  body  temperature  is  usually  increased,  chills 
may  occur,  the  peritoneum  of  the  liver  becomes  inflamed,  we  may  have 
peritoneal  friction  rubs. 

Cholangitic  infectious  processes  not  rarely  lead  to  the  appearance 
of  Ehrlich's  diazo  reaction  in  the  urine.  With  this  pathogenesis  of  the 
jaundice  variations  of  the  latter  are  easily  explained. 

c.  Cholelithiasis,  so  often  occurring  synchronously  with  cancer  of  the 
gall-bladder,  can  give  rise  to  the  appearance  of  jaundice.  The  infectious 
process  often  accompanying  cancer  of  the  gall-bladder  elicits  colic  of 
the  organ,  and  in  this  way  there  occurs  the  expulsion  of  concretions  into 
the  ductus  choledochus,  resulting  in  jaundice  due  to  obstruction.  Or 
there  may  be  jaundice  lasting  but  a  day  or  two,  coming  on  together  with 
the  painful  attacks,  this  jaundice  depending  on  swelling  (infectious  or 
vasomotor)  of  the  mucous  membranes  lining  the  gall-ducts,  or  it  may  de- 
pend upon  hyperemia  of  the  liver. 


Those  cases  in  which  icterus  makes  its  first  appearance  several  weeks 
after  a  gall-bladder  colic,  seem  to  me  especially  suspicious  of  carcinoma 
of  the  gall-bladder  (3,  4). 

The  complications  discussed  under  &,  and  c  make  it  appear  compre- 
hensible that  also  with  carcinoma  of  the  gall-bladder  the  biliary  stasis 
and  its  resultant  manifestations  in  the  urine,  such  as  elimination  of  bili- 
rubin or  urobilinogen,  and  skin  discoloration,  may  be  subject  to  more  or 
less  pronounced  variations.  The  skin  discoloration  as  such  is  less  adapted 
as  an  indicator  of  the  momentary  biliary  congestion,  because  the  disap- 

*' Compare  No.  38. 


136  TUMORS    OF    THE    ABDOMINAL    VISCERA 

pearancc  of  the  bile-pigment  in  the  skin,  especially  if  it  has  reached  a 
high  grade  and  has  lasted  a  long  time,  is  much  slower  than  the  retro- 
gression of  the  biliary  congestion. 

Edematous  infiltration  of  the  skin  may  lead  to  a  local  diminution  of 
the  jaundiced  discoloration  (3).  If,  as  is  not  seldom  the  case,  the  icterus 
diminishes  toward  the  end  (9),  it  may  occasionally  be  due  to  a  reduced 
production  of  bile-coloring  material. 

PHYSICAL    EXAMINATION    FOR   CANCER   OF   THE    GALL- 
BLADDER 

The  early  diagnosis  of  cancer  of  the  gall-bladder  presupposes  that 
the  examiner  is  in  the  habit  of  making  a  detailed  exploration  of  the  gall- 
bladder region  in  every  abdominal  case.  I  believe  I  am  not  wrong  in 
assuming  that  this  is  frequently  omitted. 

Inspection 

There  are  cases  of  carcinoma  of  the  gall-bladder  (though  they  are 
those  of  much-emaciated  patients)  in  which  the  gall-bladder  can  be  rec- 
ognized by  mere  inspection  (3).  It  bulges  forward  like  a  globular  forma- 
tion, and  with  diaphragmatic  breathing  exhibits  exquisite  movability. 

Palpation 

In  most  instances,  however,  palpation  is  required,  and  this  should  be 
tried  also  in  the  lateral  decubitus. 

Where  the  belly-walls  are  very  much  relaxed  it  is  possible — though, 
of  course,  seldom — to  grasp  the  border  of  the  liver  from  above  between 
the  thumb  and  the  fingers,  thus  also  feeling  the  great  distention  of  the 
gall-bladder. 

The  findings  differ  very  much.  The  gall-bladder  may  be  transformed 
into  a  very  thin  tumor  (21),  which  is  globular  or  pear-shaped,  the  sur- 
face sometimes  almost  angular  and  facetted  (1,  15),  (adapting  itself  to 
concretions!)  ;  but  the  walls  may  also  feel  soft  (4).  Besides  ascertaining 
the  size,  consistence  and  shape,  one  should  also  always  look  for  tenderness 
to  pressure. 

In  differential  diagnosis  it  is  only  the  lower  pole  of  a  deeply  located 
kidney  that  comes  into  consideration. 

Gall-Bladder  or  Kidney? 

The  often  difficult  distinction  will  be  based  especially  on  the  follow- 
ing considerations : 

1.  By  gliding  the  palpating  fingers  downward  over  the  lower  pole  of 
the  kidney  it  is  possible,  if  the  organ  be  movable,  to  cause  it  to  spring 
upward  after  the  manner  of  a  cherry-stone,  this  being  a  procedure  which 
is  impossible  of  accomplishment  with  respect  to  the  gall-bladder  fixed  in 
its  place.  The  kidney  which  has  thus  been  dislocated  upward  can  again 
be  displaced  downward  if  the  patient  stands  upright. 


CARCINOMA    OF    THE    GALL-BLADDER  i:JT 

The  relations  of  the  lower  pole  of  the  kidiuy  to  the  bortler  of  the 
liver  are  variable,  those  of  the  gall-bladder  are  fixed. 

2.  Accordingl}',  it  is  in  a  large  measure  possible  to  penetrate  between 
the  border  of  tlie  liver  and  a  (juestionable  tumor  when  wo  are  dealing 
with  the  lower  pole  of  the  kidney ;  the  pathologically  altered  gall-bladder 
is  frequently  fixed  to  thi-  hepatic  border,  and  penetration  is  therefore 
impossible. 

3.  A  tumor  of  the  gall-bladder  is  usually  adjacent  to  the  anterior 
abdominal  wall,  and  occasionally  even  bulges  out. 

■i.  The  movability  of  gall-bladder  tumors  with  diaphragmatic  breath- 
ing is  particularly  prompt. 

5.  Differences  in  consistence  are  not  always  present,  as  very  elastic 
tension  and  diffuse  carcinomatous  infiltration  may  be  the  equivalent  of 
the  normally  existing  difference;  frequently,  however,  the  gall-bladder 
feels  softer,  and  then  there  is  slight  trace  of  fluctuation. 

6.  With  very  much  enlargement  its  pear-shape  becomes  conspicuous, 
as  also  the  good  lateral  motion  on  the  diminishing  pedicle,  when  there  is 
absence  of  upw^ard  or  downward  mobility. 

While  the  normal  gall-bladder  is  not,  as  a  rule,  palpable,  it  is  fre- 
quently possible,  wath  carcinomatous  disease  of  the  organ,  to  feel  it.  The 
cause  for  this  does  not  always  lie  in  an  enlargement  of  the  organ ;  some- 
times even  the  reduced  and  contracted  gall-bladder  is  demonstrable.  The 
cause  seems  rather  to  be  in  the  increased  consistence,  which  in  its  turn 
may  be  due  to  increased  internal  pressure  or  to  thickening  of  the 
walls. 
"Corset  Lobes." 

Unfortunately,  even  the  gall-bladder  with  enlarged  volume  is  fre- 
quently not  palpable.  This  is  due  to  the  frequency  with  which  so-called 
"corset  lobes"  are  present  with  cholelithiasis  and  cancer  of  the  gall- 
bladder. 

The  anterior  portion  of  the  border  of  the  right  lobe  of  the  liver  is 
stretched  out  flat  like  an  apron,  separated  from  the  rest  of  the  organ 
by  a  more  or  less  deep  groove  running  in  a  horizontal  direction  on  a  level 
with  the  costal  arch,  and  behind  this  "corset  lobe"  there  is  concealed  the 
gall-bladder,  at  times  much  enlarged,  not  accessible  to  palpation.  Only 
very  exceptionally  is  the  left  lobe  of  the  liver  stretched  out  in  a  similar 
manner,  and  then  it  may  suggest  a  splenic  tumor  if  sufficient  attention  is 
not  paid  to  the  sharp  free  border. 

The  "corset  lobes"  derived  from  the  right  half  of  the  liver  may  lead 
to  a  series  of  diagnostic  errors.  If  these  lobes  are  marked  off  bj^  a  deep 
groove,  one  is  very  apt  to  assume  that  the  hepatic  border  lies  along  this 
groove;  this  the  more  so,  as  the  continuation  of  the  groove  toward  the 
left  actually  leads  to  the  border  of  the  left  lobe  of  the  liver. 

On  account  of  the  small  sagittal  diameter  of  the  "corset  lobe,"  it 
usually  yields  a  tympanitic  sound,  as  it  rests  upon  the  bowel  like  a  plexi- 
meter.  Again,  it  offers  but  little  resistance  to  the  palpating  fingers,  and 
therefore  easily   escapes   detection  by  palpation,   particularly   when   the 


138  TUMORS    OF    THE    ABDOMINAL    VISCERA 

examination  is  undertaken  in  the  dorsal  decubitus  and  not  in  both  lateral 
positions. 

Furthermore,  when  such  "corset  lobes"  extend  far  down,  they  give 
rise  to  resistances  in  the  ileocecal  region,  so  that  they  occasionally  sug- 
gest even  tumors  of  the  cecum ;  the  consequent  deep  location  of  the  gall- 
bladder may,  in  painful  affections,  lead  among  others  to  the  danger  of 
confusion  with  appendicitis. 

Corset  lobes  are  not  seldom  subject  to  distinct  ballottement,  which, 
however,  can  be  obtained  better  in  the  axillary  line  of  the  lumbar  region 
than  directly  from  the  back. 

As  a  result  of  connective-tissue  induration,  the  consistence  in  the 
proximity  of  the  "corset  groove"  is  fi-equently  increased,  so  that  one 
might  easily  imagine  a  cirrhotic  or  even  carcinomatous  process  going  on. 

As  carcinoma  of  the  gall-bladder  very  frequently  spreads  by  con- 
tinuity, the  portions  of  the  liver  immediately  adjacent  should  be  carefully 
examined  as  to  consistence,  character  of  the  surface,  etc. 

This  regional  invasion  is  not  without  meaning  for  the  diagnosis  of 
cancer  of  the  gall-bladder. 

Often  it  is  only  the  area  immediately  surrounding  the  gall-bladder 
which  is  infiltrated  and  feels  hard  as  a  board,  or  there  are  present  promi- 
nent cancer  nodules,  or  it  is  possible  upon  auscultation  and  even  pal- 
pation to  demonstrate  peritoneal  friction. ^'^ 

It  may  occasionally  occur  in  connection  with  cancer  of  the  gall-blad- 
der that  metastasis  gives  rise  to  tumors  of  the  large  omentum,  which  may 
be  easily  misleading. 


ACCOMPANYING    SYMPTOMS    FROM    OTHER    ORGANS 

Gastric  manifestations,  such  as  anorexia,  dilatation,  gastric  peris- 
talsis, vegetation  of  sarcinae  and  lactic-acid  bacilli,  "coffee-ground"  vomit- 
ing, achlorhydria,  etc.,  may  come  so  prominently  into  the  foreground 
that  they  obscui'c  the  primary  disease.  This  refers  above  all  to  those 
cases  of  cancer  of  the  gall-bladder  which  lead  to  stenosis  of  the  pylorus 
or  duodenum.^'*  Confusion  with  primary  gastric  affections  is  so  much 
more  easily  possible,  as  we  are  frequently  dealing  with  cancer  of  the  gall- 
bladder which  is  of  the  scirrhus  type,  confined  to  the  gall-bladder  and 
running  its  course  without  icterus. 

But  even  without  such  mechanical  complications  disturbances  of  the 
stomach  are  frequently  met  with.  The  syndrone,  icterus  and  continued 
anorexia,  occurring  in  advanced  age,  will  always  make  us  think  of  the 
possibility  of  cancer  of  the  gall-bladder.*^^  The  anorexia  and  intolerance 
frequently  are  limited  to  meat. 

The  biliary  stasis  as  such  probably  has  nothing  to  do  with  the  ano- 

'''Nos.  2,  6,  ]0,  20. 
'"Nos.  1,  2,  11,  15,  17,  19. 
w  No.  4. 


CARCINOMA    OF    THE    GALL-BLADDKR  139 

rcxia,  for  frequently  the  anorexia  occurs  as  the  initial  syinptoiii  without 
icterus. '^^ 

In  view  of  the  individual  differences  in  functionating  power  of  the 
organ  ("stomach  athletes"  and  "stomach  weaklings"!),  there  can  be  lit- 
tle wonder  if  in  some  cases  the  appetite  remains.''-'  Even  in  such  cases 
the  intake  of  nutrition  is  often  limited,  as  it  easily  causes  a  sensation  of 
discomfort  in  the  epigastrium  (3,  19). 

Similarly  as  in  gastric  cancer,  it  is  possible  that  in  the  beginning  of 
the  disease  formerl}'^  existing  gastric  complaints,  such  as  pyrosis,  may 
disappear  (10),  which  is  probably  due  to  a  decline  in  the  HCl  curve. 

Boivel 

Cases  beginning  with  anorexia  (2,  11)  are  usually  accompanied  by 
obstipation,  yet  a  sluggish  bowel  is  of  far  less  frequent  occurrence  with 
cancer  of  the  gall-bladder  than  it  is  with  cancer  of  the  stomach.  Even 
regulation  of  formerly  tardy  bowel  movements  may  be  observed  (8)  which 
may  have  some  connection  with  the  poor  absorption  of  fat  as  a  result  of 
biliary  stasis. 

In  rare  cases  carcinoma  of  the  gall-bladder  leads  to  severe  stenosis  of 
(11,  14),  and  may  invade  the  hepatic  flexure  of  the  colon  (20). 

Ascites 

Ascites,  which  sometimes  becomes  very  prominent  (2),  deserves  at- 
tention as  a  peritoneal  symptom.  It  may  be  the  result  of  metastasis  in 
the  peritoneum  (19,  20),  and  thus  be  due  to  carcinomatous  peritonitis 
or  be  traceable  to  a  congestion  (metastases  ad  portam  hepatis!).  The 
occurrence  of  local  areas  of  inflammation  such  as  pericholecystitis  and 
perihepatitis  with  fibi-inous  exudation  and  consequent  peritoneal  fric- 
tion, has  already  been  mentioned.  Diff'use  metastasis  into  the  liver-tissue 
with  ver}^  much  enlargement  of  the  organ  (7)  does  not  count  among  the 
frequent  occurrences.  Often  the  metastasis  is  very  slight  or  takes  place 
largely  by  continuity  in  the  immediate  proximity  of  the  gall-bladder. 
Not  infrequently  the  enlargement  of  the  organ  is  due  to  the  congestion 
of  bile,  which  may  also  lead  to  increased  consistence — though,  indeed, 
moderate^ — of  the  organ. 

Retroperitoneal  Glands 

Formation  of  metastasis  in  the  retroperitoneal  glands  may  occasion- 
ally give  rise  to  compression  of  the  inferior  vena  cava,  thus  inducing  a 
thrombosis  of  that  vessel  (3). 

Tachycardia 

Despite  prolonged  and  pronounced  biliary  congestion,  carcinoma  of 
the  gall-bladder,  and  analogously  also  carcinoma  of  the  papilla  of  Vater, 

"Nos.  2,  6,  11,  13,  14,  15,  19,  21. 
»'  Nos.  3,  10,  12,  20. 


140  TUMORS    OF    THE    ABDOMINAL    VISCERA 

are  frequently  accompanied  by  tachycardia,  thus  being  in  certain  contra- 
distinction to  benign  forms  of  icterus.  This  behavior,  however,  does  not 
depend  upon  the  cancerous  nature  of  the  disease  as  such.  Thus  the 
"mummifying"  types  of  cancer  of  the  gall-bladder  are  not  seldom  accom- 
panied by  ictcrus-bradycardia.  But  when  the  peripheral  resistance  is  in- 
creased through  the  occurrence  of  dropsy  in  the  skin  and  cavities,  or 
when  cholangitic  infectious  processes  are  added,  tach^'cardia  is  present, 
even  with  chronic  and  intense  icterus. 

Spleen 

Swellings  of  the  spleen  may  come  into  being  under  the  influence  of  a 
chronic  icterus,  through  congestion  or  cholangitic  infections. 

These,  however,  always  remain  within  moderate  limits,  hardly  ever 
exceeding  the  costal  arch,  and  very  seldom  does  the  organ  attain  the  de- 
gree of  hardness  met  with  in  cirrhosis. 


COURSE,  DURATION,  TYPES 

"Acute"  Begimiing 

Here,  as  in  cancer  of  the  stomach  or  intestine,  the  patients  frequently 
describe  an  acute  beginning.  An  attack  of  "gall-stone  colic"  is  not  sel- 
dom the  first  link  in  the  chain  of  symptoms,  and  naturally  is  an  occur- 
rence which  impresses  itself  in  the  memory  of  patients  better  than  pre- 
ceding indefinite  complaints. 

Duration 

The  clinical  duration  of  the  disease  (the  duration  of  the  anatomical 
process  cannot  be  judged)  is  a  strikingly  short  one,  at  any  rate  really 
much  shorter  than,  for  instance,  in  gastric  cancer.  I  would  assume  an 
average  duration  of  six  months  and  consider  as  unusually  long  a  duration 
of  one  year. 

Two  factors  might  here  be  adduced  by  way  of  explanation. 

In  the  first  place,  the  relative  inferiority  in  functioning  power  of  the 
organ  may  possibly  cause  a  longer  period  of  latency. 

Again,  the  frequently  existing  biliary  congestion  with  its  resulting 
phenomena,  such  as  cholemia,  cholangitis,  etc.,  may  injure  the  entire 
organism,  which  hastens  the  lethal  course. 

Types 

From  among  the  polymorphous  clinical  forms  of  manifestation  of 
cancer  of  the  gall-bladder,  several  types  may  be  more  sharply  outlined. 
These  may  here  be  briefly  noted. 

1.  "Hepatic"  Type 

Most  intense  icterus,  stationary,  painless,  with  blackish-green  dis- 
coloration, extreme  emaciation  and  mummification,  afebrile,  found  mostly 
in  very  old  women:  scirrhus  of  the  gall-bladder. 


CARCINOMA    OF    THE    GALL-BLADDER  141 

2.  "Cholang'dic"    Ti/pe^^ 

This  runs  a  febrile  course  mostly  with  moderate  rises  in  temperature, 
but  which  may  reach  considerable  elevation  (6,  10).  Diazo  reaction  in 
the  urine;  leucocytosis,  often  very  considerable. 

Icterus  of  medium  severity,  variable ;  liver  enlarged,  tender  to  pres- 
sure, often  localized  perihepatic  friction.  ]\Iostly  younger  individuals 
(40-50  years)  :  Medullary  carcinoma  (villous  cancer)  and  cholecystitis. 

This  type,  more  so  than  type  No.  1,  is  frequently  marked  by  an  attack 
of  gall-stone  colic  in  the  beginning  of  the  disease  or  during  the  course  of  it. 

3.  "Peritoneal"   Type, 

in  its  clearest  form  without  icterus,  accompanied  by  ascites,  produced  by 
peritoneal  metastasis  and  portal  congestion. 

4.  "Stomachic"  Type^^ 

Its  most  distinct  form  is  represented  by  those  cases  in  which  icterus 
is  absent  and  the  symptoms  of  a  pyloric  stenosis  are  present.  This  type, 
as  a  rule,  exhibits  the  usual  marks  of  a  benign  stenosis  (HCl  sarcinse), 
but  may  also,  though  seldom,  be  accompanied  by  achlorhydria,  "coffee- 
ground"  vomiting  and  growths  of  lactic-acid  bacilli. 

5.  "Intestinal"  Type 

Intestinal  peristalsis  as  a  result  of  stenosis  of  the  hepatic  flexure  of 
the  colon  (14). 

SUSPICIOUS  FACTORS  AND  DIFFERENTIAL  DIAGNOSIS. 

Suspicious  Factors 

So  far  as  suspicious  factors  are  the  result  of  simple  and  uncom- 
plicated considerations  they  may  here  be  briefly  grouped : 

1.  Chronic  severe  icterus  in  very  old  age,  especially  when  occurring 
in  female  patients,  is  in  the  first  place  always  suspicious  of  carcinoma 
of  the  gall-bladder. 

2.  If  gall-bladder  colic  is  followed  after  several  weeks  by  icterus 
(3,  4)  it  will  suggest  the  possibility  of  carcinoma  of  the  gall-bladder; 
the  same  counts  among  the  inducing  causes  of  gall-bladder  colic  and  must 
always  be  considered  etiologically,  especially  in  advanced  age ;  as  a  gen- 
eral thing  it  will  be  advisable  in  gall-stone  patients  to  keep  watch  in 
this  direction. 

3.  "Gall-stone  colics"  are  so  much  more  suspicious  of  cancer  when 
they  first  occur  in  old  age  without  apparent  cause  and  are  accompa- 
nied by  continued  anorexia. 

4.  Pains   below   the   right   costal   arch,   manifesting   themselves   espe- 

»*Nos.  1,  11,  19. 
»=Nos,  6,  8,  10,  Ifi. 


142  TUMORS    OF    THE    ABDOMINAL    VISCERA 

cially  when  patient  is  seated,  sliould  always  be  the  occasion  for  a  care- 
ful examination  of  the  gall-bladder. 

5.  A  rapidly  and  painlessly  developing  pyloric  stenosis  with  persis- 
tence of  HCl  secretion  and  vegetation  of  sarcin<T  is  suspicious  of  carci- 
noma of  the  gall-bladder,  the  more  so,  when  at  the  same  time  indications 
of  a  stenosis  of  the  hepatic  flexure  of  the  colon  exist. 

Dijferential   Diagnosis 

The  field  of  differential  diagnosis  varies  according  to  the  existing 
type  of  disease,  with  respect  to  which  we  refer  to  former  discussions. 

Icterus  Catarrhalis 

So  far  as  the  "hepatic"  or  "cholangitic"  types,  which  are  accompanied 
by  icterus,  are  concerned,  it  will  be  well  to  keep  in  mind  that  icterus 
catarrhalis  is  rare  after  the  fortieth  year  of  life. 

Biliary  Cirrhosis 

Neither  are  "biliary  cirrhoses,"  frequently  met  witli  in  older  age, 
say  after  the  50th  year.  In  doubtful  cases  hemeralopia  would  speak  in 
favor  of  Hanoi's  cirrhosis,  ascites  in  favor  of  carcinoma,  providing  the 
liver  be  enlarged  and  intense  icterus  be  present.  A  splenic  tumor  extend- 
ing below  the  costal  arch  and  accompanied  by  leucopenia  corresponds 
more  to  the  picture  of  a  biliary  cirrhosis. 

Primary  Cholangitis 

Chronic  icterus  as  a  result  of  primary  infectious  cholangitis  is  decid- 
edly rare;  far  more  frequent  is  infection  of  the  biliary  passages  associating 
itself  with  neoplasms  of  the  biliary  passages  (gall-bladder  and  papilla 
of  Vater).  A  high  febrile  course  with  hyperleucocytosis  (10)  and  diazo 
reaction  must  not  deter  us  from  suspecting  a  neoplasm  being  thus  situated. 

Impaction  of  Calculus 

Icterus  due  to  occlusion  of  the  ductus  choledochus  bj'  a  calculus  almost 
always  sets  in  immediately  after  a  severe  attack  of  colic. 

Ucliinococcus 

Echinococcus  cysts  only  very  exceptionally  lead  to  severe  icterus ; 
this  extraordinarily  rare  possibility  must,  however,  be  borne  in  mind, 
because  comparatively  eas}^  surgical  interference  may  in  these  instances 
be  life-saving. 

Perihepatic  Friction 

This  is  met  with  much  more  frequently  in  connection  with  malignant 
icterus  than  with  benign  forms. 

Among  the  malignant  processes  accompanied  by  icterus  gravis  besides 
cancer  of  the  gall-bladder  we  have  practically  to  take  into  consideration 
only  carcinoma  of  the  head  of  the  pancreas  and  carcinoma  of  the  papilla 
of  Vater. 


CARCINOMA    OF    THE    GALL-BLADDER 


143 


Gall-Bladder. 

Icterus  curve  rarely  in- 
termittent. 

Febrile  course ;  at  times 
diazo  reaction  and 
high  leucocytosis, 
cholangitic  accompa- 
nying manifestations 
such  as  perihepatitis, 
etc. 


Gall-bladder  at  times 
contracted,  infiltrat- 
ed with  cancer;  ex- 
ceptionally soft,  en- 
larged. 

"Corset  lobes"  very 
frequent. 

Cholelithiasis,  at  times 
a  previous  history  of 
typhoid. 

Trypsin  test  (feces) 
positive. 


Head  of  the  Pancreas. 

Icterus  curve  rising  or 

stationary. 
Mostly      afebrile ;      no 

cholangitis. 


Glycosuria  spontane- 
ous or  alimentary 
(rare). 

Gall-bladder  enlarged. 


Trypsin  test  ^*^  in  the 
feces  at  times  nega- 
tive. 

Systolic  murmur  over 
the  abdominal  aorta 
in  the  epigastrium. 


Papilla    of    Vater. 

Icterus  curve  often  in- 
termittent. 

Febrile  course  very  fre- 
quent, likewise  cho- 
langitic accompany- 
ing manifestations. 


Gall-bladder  enlarged. 


Bowel  hemorrhages,"^  if  at  all,  oc- 
curring only  late. 


Occult    bowel    hemorrhage    as    an 
early  symptom. 


The  foregoing  tabulation  is  designed  throughout  to  meet  cases  ac- 
companied by  intense  biliary  congestion,  hence  severe  icterus. 

Just  as  there  are  no  iron-clad  rules  in  differential  diagnosis,  so  also 
here  the  distinguishing  marks  possess  only  conditional  value. 


^  In  view  of  the  uncertainty  as  to  what  extent  the  pancreas  is  responsible  for 
functional  disturbances  analogous  to  achylia  gastrica,  negative  findings  will  have  to  be 
used  cautiously;  positive  findings,  though,  may  be  estimated  higher  in  value. 

*"  Here  negative  findings  are  much  more  important  than  positive  ones.  The  lack  of 
urobilinogen  seems  to  have  some  bearing  on  the  fact  that  often  even  very  slight  amounts 
of  blood  in  alcoholic  stools  yield  a  strongly  positive  chemical  blood  test.  Here  only 
larger  admixtures  of  blood  are  of  value  for  the  diagnosis  of  ulcerative  processes.  Such 
admixtures  of  blood  may  be  recognized  macroscopically  at  times  by  the  brownish  color 
which  they  impart  to  the  feces  that  are  free  from  urobilinogen,  and  microscopically  by 
the  presence  of  amorjihous  flakelike  blood  pigment. 


144  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Cancer  of  the  Pancreas 

Carcinomas  of  the  pancreas  often  remain  free  from  ulcerative  proc- 
esses for  a  long  time,  and  this  explains  the  mostly  afebrile  course  of  the 
disease,  which  is  in  particular  contradistinction  to  the  cholangitic  infec- 
tious processes  often  occurring  early  with  carcinoma  of  the  papilla  of 
Vater   (ascending  infection   from  the  ulcerating  surface). 

In  not  too  far  advanced  stages  the  demonstration  of  occult  hemor- 
rhages in  the  feces  is  at  times  certainly  significant  for  the  assumption 
of  a  cancer  of  the  papilla  of  Vater.  Just  prior  to  death  it  is  possible 
that  also  with  cancer  of  the  gall-bladder  (12)  and  of  the  head  of  the 
pancreas  there  may  occur  intestinal  hemorrhage  due  to  portal  congestion 
and  penetration  of  the  pancreatic  cancer  into  the  duodenum, 

Indican 

I  do  not  attach  any  particular  diagnostic  significance  to  the  result 
of  the  indican  reaction  in  the  urine.  It  may,  for  example,  be  perma- 
nently absent  in  cancer  of  the  gall-bladder  (15),  without  any  demon- 
strable lesion   in  the  pancreas  or  its   excretory  channels. 

In  Case  7  the  reaction  was  for  a  long  time  negative,  and  became 
positive  only  with  the  appearance  of  peritonitic  symptoms. 

Neutral  Fat 

The  appearance  of  neutral  fat  in  the  feces  does  not  seem  to  have 
any  other  meaning  than  that  the  biliary  occlusion  is  a  very  severe  one. 

Diazo  Reaction 
Hyperleucocytosis 

It  seems  to  me  that  like  cholangitic  complications,  so  also  diazo  reac- 
tion and  hyperleucocytosis  (6)  are  much  less  frequent  with  cancer  of 
the  head  of  the  pancreas. 

Laennec's  Cirrhosis 

As  far  as  forms  of  gall-bladder  cancer  which  run  their  course  without 
icterus  are  concerned,  the  cirrhosis  of  Laennec  in  the  first  stage  will 
occasionally  enter  into  differential  diagnosis.  Lack  of  corresponding 
swelling  of  the  spleen,  circumscribed  tenderness  on  pressure  (correspond- 
ing to  subperitoneal  cancer  masses),  at  times  with  perihepatic  friction 
sounds  in  the  painful  area,  febrile  movements,  ascites,  etc.,  would  be 
findings  pointing  rather  to  malignancy. 

Pyloric  Stenosis 

Pyloric  stenosis  would  have  to  make  us  think  of  cancer  of  the  gall- 
bladder as  the  cause,  when  the  symptoms  date  back  but  a  short  time 
(several  months)  and  peristalsis  goes  on  painlessly  despite  persistence 
of  HCl.  Neither  condition  applies  to  stenosis  resulting  from  internal 
ulceration.  The  previous  history  in  these  cases  usually  dates  back  many 
years,  and,  under  the  influence  of  HCl  irritation,  peristalsis  goes  along, 
mostly  accompanied  with  violent   colics. 


Carcinoma  of  the  Pancreas 


The  colorlessness  of  the  pancreatic  secretion  is  a  factor  which  in  and 
of  itself — as  compared  to  analogous  diseases  of  the  liver — renders  the 
diagnosis  of  carcinoma  of  the  pancreas  difficult ;  the  main  difficult}', 
however,  arises  from  the  concealed  location  of  the  organ. 

There  are  chiefly  two  ways  in  which  the  cancer  proliferation  may 
make  its  clinical  appearance  already  in  the  early  stages,  even  though 
the  anatomical  limits  of  the  organ  have  not  been  exceeded,  namely: 

o.  Compression  of  the  channels  of  elimination  within  the  gland:  duc- 
tus choledochus  and  ductus  pancreaticus.  This  possibility  applies  at 
least  to  cancers  located  in  the  head  of  the  pancreas. 

&.' Irritation  of  pancreatic  nerves  and  nerve  plexuses  with  secondary 
phenomena  of  pain. 


EARLY    SYMPTOMS 

Phenomena  of  Pain 

a.  Phenomena  of  Pain. 

Though  there  is  the  undoubted  possibility  that  cancer  proliferations 
in  the  pancreas  lead  to  the  early  appearance  of  painful  phenomena,  it 
must,  on  the  other  hand,  be  emphasized  that  sensations  of  pain  referable 
to  the  pancreatic  tumor  itself  are  often  absent   (1,  3,  4). 

At  any  rate,  pains  that  are  constant,  felt  deep  in  the  epigastrium  and 
located  posteriorly  in  the  back,  of  great  severity  and  at  times  depending 
upon  body  position,  will  occasionally  awaken  the  suspicion  of  a  new 
formation  in  the  pancreas.  Of  course,  the  same  ensemble  of  pains  may 
be  observed  also  in  other  retroperitoneal  malignant  new-growths  (such 
as  gland  metastases,  lymphosarcoma),  its  intensity  being  in  proportion 
to  the  extent  of  the  retroperitoneally  located  malignant  process.  Ex- 
tension of  the  malignant  process  to  the  vertebral  column,  of  course, 
affords  specially  favorable  conditions.  The  objective  examination  for 
pain  in  such  cases  will  easily  elicit  tenderness  deep  in  the  epigastrium, 
and  at  times  also  along  the  spinous  processes  of  the  lumbar  vertebra? 
and  the  sacrum  (2,  6). 

Other  painful  phenomena  occurring  during  the  course  of  carcinoma 
of  the  pancreas  are  of  such  nature  as  rather  to  divert  attention  from 
the  underlying  process. 

Thus,  for  example,  there  may  often  be  great  tenderness  to  pressure, 
and  also  spontaneous  pains  in  the  region  of  the  gall-bladder  if  it  is 
greatly  distended  because  of  compression  of  the  ductus   choledochus  in 

145 


146  TUMORS    OF    THE    ABDOMINAL    VISCERA 

the  head  of  the  pancreas  (3,  5).  Or  there  may  occur  hepatalgias  result- 
ing from  perihepatitis  due  to  cancerous  infiltration  of  the  liver,  or  dis- 
tention of  the  liver  capsule  due  to  biliary  congestion  or  cholangitic 
processes. 

If,  as  a  result  of  duodenal  or  pyloric  stenosis,  the  walls  of  the  stom- 
ach are  overtaxed,  there  may  occur  gastralgias,  which  occasionally  also 
radiate  into  the  back  (2).  Relieving  the  stomach  of  excessive  internal 
pressure,  be  it  by  means  of  belching  of  gas,  vomiting  or  bowel  evacua- 
tions, usually  has  a  verv  favorable  efl'ect  on  this  kind  of  pain  in  the 
back. 

Stasis  of  Biliary  and  Pancreatic 
Secretion 

b.   Stasis  of  Biliary  and  Pancreatic   Secretion. 

Even  with  quite  diffuse  cancerous  infiltration  of  the  pancreas,  the 
ductus  choledochus  may  escape  compression ;  without  further  comment, 
this  is  comprehensible  when  the  new-growth  is  located  in  the  tail  or 
middle  portions.  The  predominating  occurrence,  however,  of  cancer 
proliferation  in  the  head  of  the  pancreas  accounts  for  the  fact  that 
biliary  congestion,  and  hence  icterus,  count  among  the  frequent  symp- 
toms of  cancer  of  the  pancz-eas. 

In  this  respect  it  will  be  of  importance  to  recognize  the  biliary  con- 
gestion in  its  incipient  stages,  in  regard  to  which  we  refer  to  previously 
given  details  (page  35).  Great  practical  significance  attaches  also  here 
to  Ehrlich's  aldehyde  reaction. 

"Pancreatogenous"  Icterus 

If  pronounced  icterus  has  set  in,  special  attention  should  be  given 
to  the  following  findings,  in  order  to  make  a  rapid  differential  diagnosis : 

a.  Decided  enlargement  of  the  gall-bladder,  the  demonstration  of 
which  often  meets  with  difficulties,  especially  in  the  presence  of  "corset 
lobes"  of.  the  liver. 

b.  The  icterus  often  sets  in  without  pain ;  at  least,  there  is  no  severe 
colic  (as  compared  to  gall-stone  colic  with  an  occluding  calculus  in  the 
ductus   choledochus). 

c.  The  icterus  is  mostly  unaccompanied  by  fever,  at  least  so  long 
as  there  is  no  ulceration  extending  into  the  duodenum  (blood-coloring 
matter  in  the  feces),  which  latter,  if  present,  might  indeed  easily  lead 
to  ascending  infections  of  the  biliary  passages. 

d.  Hardly  any  variations  in  the  icterus,  but  rather  constant  progress- 
iveness  up  to  a  melanotic  icterus  with  complete  biliary  occlusion,  and  at 
times  absence  of  the  aldehyde  reaction  in  alcoholic  extract  of  stool. 


Ohstr acted  Flow    of  Pancreatic  Juice 
and  Its  Demonstration 

Those  cases  of  cancer  of  the  head  of  the  pancreas  accompanied  by 
complete  obstruction  to  the  flow  of  bile  are  probably  also  accompanied 


CARCINOMA    OF    THE    PANCREAS  U7 

by  total  shutting  off  of  the  flow  of  pancreatic  juice;  but  it  is  also 
within  the  realms  of  possibility  that  there  be  an  isolated  blocking  of 
the  secretion  of  the  "abdominal  salivary  gland." 

The  question,  therefore,  arises  as  to  what  criteria  we  have  for  assum- 
ing a  cessation  of  external  secretion  of  the  pancreas  into  the  duodenum. 

Trypsin  Demonstration 

1.  Absence  of  the  normal  proteolytic  digestive  energy  in  the  super- 
natant portion  of  feces. 

The  briefest  and,  at  the  same  time,  most  reliable  procedure  is  Miiller 
and  Schlechfs^^^  modification  of  Sahli's  "capsule  method." 

Here  the  effects  of  the  proteolytic  ferments  of  the  feces  are  exerted 
upon  properly  hardened  gelatine  capsules  that  contain  charcoal  (Capsul. 
geladurata?  c.  carb.  ligni  0.3,  original  filling  by  the  firm  of  G.  Pohl, 
Schonbaum,  Danzig). 

According  to  Stanick,''^'^  spontaneously  evacuated  stools  may  be  mixed 
with  an  equal  quantity  of  1%  soda  solution,  thoroughly  rubbed  up  and 
then  used  for  the  test,  thus  doing  away  with  the  necessity  of  a  test  diet. 

The  capsule  is  dissolved  in  the  supernatant  liquid  of  normal  stools  in 
1/^  to  1  hour;  if  it  does  not  go  into  solution  after  the  lapse  of  24'  hours, 
the  test  is  to  be  considered  as  entirely  negative. 

If  diluted  with  10%  glycerin  water,  1 :  100  solution  results  20  to  24< 
hours  at  37°  C. 

As  it  is  the  complete  absence  of  any  proteolytic  action  that  is  of 
chief  diagnostic  importance,  it  will  frequently  be  possible  to  confine  one's 
self  to  an  examination  of  the  original  supernatant  liquid  of  the  stools. 

The  test  is  best  performed  in  the  incubator  at  a  temperature  of 
37°  C.  (higher  temperature  would  in  and  of  itself  cause  the  capsule  to 
go  into  solution),  and  in  order  to  avoid  any  action  on  the  part  of  bac- 
terial ferments  a  little  chloroform  or  a  few  crystals  of  thymol  may  be 
added. 

The  test  may  also  be  carried  out  at  the  higher  room  temperatures 
(proximity  of  the  stove). 

It  must  be  borne  in  mind  that  large  admixtures  of  blood  or  a  high 
fat  content  may  induce  an  attenuation  of  the  contained  ferments.  In 
the  latter  case,  if  the  finding  proved  negative,  it  would  be  advisable  to 
dissolve  out  the  fat  with  ether. 

Large  admixtures  of  pus  practically  enter  into  but  little  considera- 
tion. They  could,  however,  in  and  of  themselves  produce  proteolytic 
fermentative  action. 

If  in  a  case  otherwise  clinically  suspicious  of  carcinoma  of  the  pan- 
creas, there  results  a  totally  negative  outcome  of  the  Miiller  and  Schlect 
capsule  test,  additional  ground  strengthening  the  suspicion  has  been 
gained.  A  positive  outcome  admits  as  very  probable  the  conclusion  that 
the  pancreatic  secretion  is  flowing  into  the  duodenum,  but  naturally  does 
not  permit  the  assumption  that  the  pancreas  is  intact. 

'«Med.  Klinik,  1909,  Nos.  16  and  17. 
"^aMed.  Klinik,  1910,  No.  26, 


148  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Through  the  complete  failure  of  the  Cammidge  reaction,'''^  to  which 
we  cannot  attribute  any  diagnostic  significance  in  the  semiology  of  pan- 
creatic cancer,  the  methods  of  "trypsin"  demonstration  have  gained  in 
interest. 

2.   Simultaneous  serious  impairment  of  fat  and  albumin  reduction. 

Steatorrhea   and  Azotorrhea 

This  may  bring  about  the  presence  in  the  feces  of  abundant  neutral 
fat  globules  and  intact  transversely  striated  muscle  fibres.  An  entirely 
negative  result  of  qualitative  analysis  for  indican  in  the  urine  indicates 
that  there  is  complete  cessation  of  albumin  reduction  in  the  bowel. 

Maximal  interference  with  such  reduction  may  naturally  also  lead  to 
specially  copious  stools,  as  in  fact  they  are  much  observed  in  connection 
with  carcinoma  of  the  pancreas. 

Even  the  rapidly  progressive  and  severe  cachexia  may  be  partly  in- 
terpreted as  cachexia  due  to  inanition. 

With  respect  to  the  alimentary  findings  of  steatorrhea  and  azotorrhea 
in  the  feces,  as  just  referred  to,  it  must  be  emphasized  that  apparently 
even  with  complete  occlusion  of  the  excretory  passages  of  the  "abdominal 
salivary  gland,"  there  are  no  macroscopical  or  microscopical  findings 
deviating  to  any  great  extent  from  the  normal.  It  would  seem  that  with 
appropriate  conditions  in  the  digestive  tract  there  is  a  possibility  of 
more  or  less  perfect  compensation.  Negative  findings,  therefore,  do  not 
have  any  diagnostic  significance. 

On  the  other  hand,  in  those  cases  which  are  accompanied  by  dimin- 
ished reduction  of  albumin  and  fat,  the  explanation  for  these  findings 
is  to  be  undertaken  only  after  a  control  diet  and  after  a  consideration  of 
various  possible  causes. 

If  at  all  possible,  it  Avill  always  be  advisable  to  place  an  individual  with 
normal  digestive  energy  upon  a  like  diet,  though  I  do  not  wish  to  inti- 
mate that  this  should  be  a  rigid  test  diet. 

With  severe  biliary  congestion,  as  often  found  in  connection  with 
cancer  of  the  pancreas,  it  is  hardly  ever  possible  from  the  fat  contents 
of  the  stools  to  determine  with  certainty  whether  the  fatty  stools  are 
due  only  to  deficiency  of  bile  in  the  intestine  or  also  to  lack  of  pancreatic 
secretion. 

Amorphous  or  globular  neutral  fat  is  found  in  the  severer  forms  of 
steatorrhea  even  without  participation  of  the  pancreas,  and  on  the  other 
hand  soap  needles  may  be  present  in  the  affections  of  the  pancreas  with 
occlusion  of  the  excretory  channels,  showing  up  abundantly  in  the  feces 
under  the  microscope,  this  being  due  to  the  fact  that  the  fat  splitting 
may  take  place  under  bacterial  influence. 

Steatorrhea  may  be  of  diagnostic  value  when  occurring  without 
biliary  congestion,  or  at  least  when  its  intensity  is  strikingly  dispropor- 
tionate to  the  slight  degree  of  bile  stasis. 

In  such  cases  the  microscopic  finding  of  amorphous  or  globular  neu- 

'"  Compare   O.  Schiimm   and   C.  Heijler.   Miinch.  nied.  Woch.,   1909. 


CARCINOMA    OF    THE    PANCREAS  149 

tral  fjit  would  be  significant,  as  it  is  always  an  indicator  of  an  especially 
deficient  fat  reduction. 

If,  however,  the  unabsorbed  amount  of  fat  is  so  small  that  it  has 
been  perfectly  split  up  so  that  only  soap  needles  are  visible  under  the 
microscope,  great  caution  will  have  to  be  observed  even  when  biliary 
stasis  is  absent. 

Such  findings  are  met  with  among  others  in  diarrheas  (e.g.,  per- 
nicious anemia),  in  processes  of  the  mesenteric  glands,  severer  grades 
of  intestinal  atony,  in  purulent  and  ulcerating  gastro-intcstinal  processes. 

Obviously,  in  judging  of  the  deficiency  of  fat  in  the  feces,  it  will  be 
necessary  to  know  the  amount  of  fat  that  has  been  introduced  per  os 
and  at  times  per  anum  in  the  form  of  oil  enemas  and  suppositories. 

Muscle  Fibres 

With  equal  precaution  and  discretion  we  must  interpret  the  micro- 
scopical finding  in  the  feces  of  transversely  striated  muscle  fibres. 

Besides  gastric  affections,  which  are  accompanied  by  subacidity, 
atonic  gastro-intestinal  conditions  must  be  taken  into  consideration  as 
causative  factors ;  similarly  also  increased  peristalsis  as  occurring  in 
diarrheas. 


ACCOMPANYING    SYMPTOMS    FROM    OTHER    ORGANS 

Anorexia 

Aside  from  anorexia,  which  may  occur  as  an  accompanying  symp- 
tom of  any  disease  leading  to  cachexia,  gastric  manifestations  frequently 
set  in  during  the  course  of  carcinoma  of  the  pancreas  which  have  their 
origin  in  the  topographical  relation  between  the  head  of  the  pancreas 
and  duodenum  and  are  caused  by  stenosis  of  the  latter. 

Sarcince   Vegetation 

Thus  under  certain  circumstances  there  is  an  abundant  growth  of 
sarcinae  in  the  stomach  (2)  which  are  eliminated  in  the  feces;  dilatation 
of  the  stomach  with  prolonged  splashing  sounds,  peristaltic  unrest  of 
the  antrum  pylori  (2),  a  feeling  of  fulness  and  belching  of  gas  (1)  are 
resultant  manifestations  of  difficult  emptying  of  the  stomach. 

Melena 

In  the  final  stages  of  cancer  of  the  pancreas  there  may  be  invasion  of 
the  duodenum  leading  to  continued  "occult,"  that  is,  onh^  to  chemically 
demonstrable  melena  or  even  to  copious  bowel  hemorrhage  (3).  Pro- 
liferation of  carcinomatous  masses  into  the  mesentery  may  also  give  rise 
to  ulcerated  changes  in  the  bowel  (1). 

Invasion  of  the  portal  vein  also  may  lead  to  bloody  stools  in  the 
terminal  stages,  the  more  so  if  under  the  influence  of  a  chronic  icterus  a 
hemorrhagic  diathesis  has  been  established. 


150  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Liver 

The  frequency  of  the  scirrhus  form  of  cancer  of  the  pancreas  prob- 
ably accounts  for  the  comparative  rarity  of  voluminous  metastases  in 
the  liver ;  the  enlargement  of  the  liver  usually  remains  within  moderate 
bounds  and  frequently  depends  in  great  measure  upon  biliary  stasis. 
The  importance  of  a  visible  and  greatly  distended  gall-bladder  has 
already  been  mentioned. 

Spleen 

Pressure  of  cancer-masses  on  the  splenic  vein  may  lead  to  a  hard 
splenic  tumor  (4),  which,  however,  generally  does  not  extend  below  the 
costal  arch. 

Ascites 

Metastasis  in  the  peritoneum  usually  produces  ascites,  which  makes 
it  impossible  to  feel  the  primary  tumor. 

Simultaneous  cancerous  infiltration  of  the  great  omentum  may  give 
rise  to  tumor-masses  in  the  left  half  of  the  epigastrium. 

Skin  Pigmentation 

The  occasional  occurrence  of  bronze-like  discolorations  of  the  skin, 
similar  to  that  of  Addison''s  disease,  is  common  to  carcinoma  of  the  pan- 
creas and  other  processes  leading  to  cachexia  (gastric  cancer,  pernicious 
anemia,  tuberculosis  of  the  pancreas,  etc.). 

Individuals  who  are  rich  in  pigment  seem  to  be  more  predisposed  to 
this  hemochromatosis  of  HeckVmghmisen  ■  accidental  causes  are  occasion- 
ally found  in  factors  which  are  able  even  physiologically  to  produce  in- 
creased cutaneous  pigmentation  (eflfects  of  sunlight,  etc.). 

Abdominal  Aorta 

The  topographical  relation  of  the  pancreas  to  abdominal  aorta  and 
the  possibility  of  compression  of  tiie  latter  affords  a  natural  explanation 
for  the  occasional  occurrence  of  systolic  epigastric  murmurs.^*'"  This 
auscultatory  phenomenon  should  constantly  be  borne  in  mind  when  we 
are  trying  to  determine  any  resistance  that  is  obscure  and  corresponds 
to  the  head  of  the  pancreas. 

Olycosuria 

Similarly,  we  should  always  examine  for  glycosuria.  However,  in 
view  of  the  fact  that  conditions  of  dyscrasia,  as  has  been  experienced, 
may  have  been  pre-existent,  the  symptom  will  have  to  be  interpreted  with 
caution. 

Doubtless  there  are  cases  in  which  the  history  or  continuous  obser- 
vation enables  us  to  determine  a  clear  relation  between  the  glycosuria 
and  the  diseased  condition  of  the  pancreas. 

^""See  No.  88. 


CARCINOMA    OF    THE    PANCREAS  151 


SUSPICIOUS    FACTORS    AND    DIFFERENTIAL    DIAGNOSIS 

It  will  be  advisable  to  take  into  consideration  the  possibility  of  pan- 
creatic cancer,  especially  if  the  following  premises  are  fulfilled. 

Suspicious  Factors 

1.  Melanotic   icterus  with  enlarged  gall-bladder. 

2.  Glycosuria  in  advanced  age,  with  anorexia  and  pains  in  tlie  back. 

3.  Glycosuria  with  painful  attitude  (4). 

4.  Continued  and  abundant  finding  of  sarcina-  in  gastric  contents 
with  concomitant  icterus. 

5.  Violent  pains  in  the  back  with  epigastric,  systolic  murmurs. 

6.  Cachexia  and  melanodermia. 

7.  Cachexia  and  ascites  from  unknown  causes. 

8.  Violent  pains  in  the  back  not  yielding  to  therapeutic  measures. 
These  and  similar  considerations  ought  always  to  be  the  occasion  for 

a  careful  palpatory  examination  deep  in  the  epigastrium,  and  in  order 
to  exclude,  as  far  as  possible,  all  gastro-intestinal  meteorism,  the  exami- 
nation should  be  made  on  a  fasting  stomach  or  after  a  transient  absten- 
tion from  food  and  evacuation  of  the  gastro-intestinal  contents. 

Being  situated  retroperitoneally,  pancreatic  tumors  will  be  mostly 
immobile ;  but  if  they  extend  far  anteriorly  they  may,  similar  to  kidney 
tumors,  reach  a  certain  degree  of  respiratory  mobility. 

Auscultation  should  always  go  hand  in  hand  with  deep  exploration 
of  the  epigastrium ;  a  systolic  vascular  murmur,  at  times  produced  by 
compression  of  the  aorta,  may  be  an  important  symptom  confirming  the 
assumption  of  a  deep-seated  aggressive  neoplasm  in  that  location. 

Differential  Diagnosis 

With  a  clearly  demonstrable  hard  retroperitoneal  tumor-mass  in  the 
epigastrium,  the  field  of  differential  diagnosis  is  not  a  large  one. 

Retroperitoneal  Gland  Tumors 

Lymphosarcomatous  gland  processes  and  metastatic  gland  tumors 
would  have  to  be  taken  into  particular  consideration.  This  last  kind  of 
misinterpretation  is  easily  conceivable,  especially  in  those  cases  where 
the  primary  neoplasm  runs  a  latent  course,  e.g.,  carcinoma  of  the  testicle 
without  any  enlargement  of  the  organ. 

If  a  definite  swelling  corresponding  to  the  location  of  the  pancreas 
cannot  be  felt,  which  is  true  probably  of  the  majority  of  cases,  the  field 
of  differential  diagnosis  will  depend  upon  the  existing  accompanying 
symptoms. 

Icterus   Catarrhalis  Biliary   Cirrhosis 
Ohstructing    Calculus 

If  icterus  is  present,  then  cachexia  sets  in  so  rapidly  that  confusion 
with  benign  forms  of  icteinis,  such  as  icterus  catarrhalis,  biliary  cirrhosis, 
stone  occlusion  of  the  ductus  choledochus,  will  hardly  occur.     In  con- 


152  TUMORS    OF    THE    ABDOMINAL    VISCERA 

tradistinction  to  the  two  first-mentioned  diseases,  there  is,  above  all,  the 
frequent  considerable  enlargement  of  the  gall-bladder,  which  will  serve 
as  an  important  guide. 

Occlusion  of  the  ductus  choledochus  by  a  calculus  will  be  ushered  in 
by  at  least  one  severe  attack  of  colic  in  the  midst  of  general  good  health. 
This  may,  of  course,  be  in  perfect  agreement  with  an  enlarged  gall- 
bladder. 

Cicatrix  of  the  Duodenum 

Among  other  benign  affections  occasionally  to  be  considered  are 
ulcerating  cicatricial  processes  in  the  duodenum,  as  they  also  may  lead 
to  the  syndrome  of  "gastric  stagnation  with  biliary  stasis."  But  here  the 
previous  history  dating  far  back  will,  in  most  instances,  permit  of  a  dif- 
ferentiation, because  an  acute  course  is  generally  the  rule  in  carcinoma 
of  the  pancreas.  A  duration  of  six  months  may  be  considered  as  very 
long. 

Carcinoma  at  the  Papilla 

of    Vater 

Duodenal  carcinoma,  particularly  at  the  papilla  of  Vater,  may  easily 
pass  as  a  sort  of  double  among  the  malignant  diseases. 

The  most  important  marks  of  differentiation  are  the  early  occur- 
rence of  febrile  cholangitic  processes  and  the  early  appearance  of  occult 
intestinal  hemorrhages. 

So  long  at  least  as  carcinomas  of  the  pancreas  do  not  ulcerate  into  the 
duodenum,  they  run  along  afebrile,  and  there  is  no  occasion  for  bowel 
hemorrhages. 

Diabetes  Mellitus 

Cases  accompanied  by  glycosuria  but  without  icterus  may  occasion- 
ally be  straightway  taken  for  diabetes  mellitus ;  if  one  makes  it  a  rule  to 
examine  the  region  of  the  liver  and  pancreas  carefully,  there  will  be  less 
danger  of  an  erroneous  diagnosis. 

Genital  Tumor 

Metastases  in  tlie  peritoneum  and  so  into  the  pouch  of  Douglas  make 
confusions  with  gynecological  affections  conceivable,  as  is  shown  in 
Case  6. 

Ascites  with  obscure  etiology — especially  those  forms  accompanied 
by  hemorrhagic  or  "milky"  effusion — should  always  remind  us  of  car- 
cinoma of  the  pancreas. 


Malignant  Tumors  of  the  Kidney 

In  contradistinction  to  analogous  diseases  in  the  chylo-poetic  sys- 
tem, the  intake  of  nutrition  is  very  often  not  disturbed  in  connection 
with  malignant  new-growths  of  the  kidney,  so  that  with  intact  function 
of  the  chylo-poetic  system  there  is  lacking  one  of  the  chief  conditions 
for  cachexia,  namely,  undernutrition. 

In  addition  to  this  we  are  dealing  with  a  paired  organ,  and  hence 
the  possibility  of  perfect  compensation  when  only  one  side  is  affected. 

Both  of  these  factors  perhaps  account  for  the  regrettable  fact  that 
early  diagnosis  of  malignant  new-formations  of  the  kidney  is  so  infre- 
quent, but  this  should  also  be  a  mighty  spur  to  strive  for  an  early  diag- 
nosis, so  that  the  patient  while  still  in  the  best  of  health  may  receive  the 
benefit  of  the  live-saving  operation. 


EARLY    SYMPTOMS 

1.   Pain  phenomena. 

Though  by  no  means  specifically  indicating  the  kind  of  disease,  care- 
ful study  of  the  subjective  sensations  of  the  patient  may  here,  as  in  so 
many  other  cases,  materially  hasten  early  diagnosis  in  so  far  as  the  renal 
nature  being  recognized,  it  gives  occasion  for  an  exact  detailed  examina- 
tion of  the  organ  and  its  excretion. 

Whilst  the  presence  of  the  tumor-mass,  as  such,  subjects  the  renal 
capsule  to  increased  tension,  there  becomes  added  to  this  the  fact  that 
renal  tumors  frequently  are  extraordinarily  rich  in  blood-vessels,  so  that 
further  intracapsular  increases  in  pressure  may  occur  through  active 
and  passive  hyperemia,  hemorrhage,  etc. 

Intrarenal  painful  sensations  elicited  in  such  manner  are  mostly  con- 
tinuous, and  do  not  have  that  paroxysmal  intermittent  character  peculiar 
to  ureteral  colics.  Not  rarely  they  confine  themselves  to  the  seat  of  the 
disease,  therefore  localized  in  the  lumbar  region  (3). 

"Pseudo"  Lumbago 

There  is  always  the  constant  danger  that  they  be  interpreted  as 
muscle  pains  in  the  nature  of  a  lumbago,  the  more  so,  as  movements  such 
as  stooping,  lifting,  etc.,  aggravate  them  or  evoke  their  initial  occur- 
rence (3). 

Contraction  of  the  belly-wall  leads  to  venous  congestion  in  the  abdo- 
men, and  this,  as  well  as  any  kind  of  compression  of  the  abdominal  con- 

153 


154  TUMORS    OF    THE    ABDOMINAL    VISCERA 

tents,  may  have  the  effect  of  eliciting  pain  at  the  locus  minoris  resis- 
tentirT. 

As  opposed  to  lumbago  and  analogous  affections  there  will  be  the 
occasional  unilateral  localization,  the  particular  stubbornness  of  the 
pains  and,  last  but  not  least,  the  findings  with  reference  to  kidneys  and 
urine. 

The  existence  of  a  "painful  attitude"  ^-'^  also  should  be  looked  for  in 
suspected  cases.  The  oftentimes  great  mobility  of  renal  tumors  favors 
its  occurrence. 

"Renal"  Iscliias 

Particular  attention  will  be  called  for  if  the  lumbar  pains  are  ac- 
companied by  neuralgic  sensations  in  the  lower  extremity  of  the  same 
side  (1).  Also  isolated  neuralgias  may  appear,  due  to  reflex  action 
("renal"  ischias!). 

Scrotal  Pain 

The  scrotum  may  become  the  seat  of  permanent  violent  pains  due  to 
varicocele  coexistent  with  and  dependent  upon  the  kidney  tumor,  and  in 
this  way  lead  to  the  performance  of  semi-castration,  as  mentioned  in  a 
case  observed  by  Alhrecht.^^^^ 

Ureteral   Colics 

The  passage  of  clotted  blood  or  tissue-shreds  through  the  ureter 
furnishes  a  new  source  of  pain,  and  there  may  occur  attacks^"-'^  which,  in 
opposition  to  the  pain  phenomena  so  far  discussed,  distinguish  them- 
selves by  their  acute  appearance  and  acute  course,  in  other  respects  re- 
sembling the  attacks  occurring  in  connection  with  nephrolithiasis  and 
which  must  be  looked  upon  as  ureteral  colics. 

The  more  numerous  the  symptoms  with  reference  to  the  urine  and 
urinary  elimination,  the  more  pronounced  the  characteristic  radiations 
into  the  genital  region  and  the  lower  extremities,  the  easier  it  will  be  to 
correctly  interpret  the  attacks  as  ureteral  colics. 

Ch olelithiasis,  Appendicitis 

Intense  appearance  of  gastric  symptoms,  such  as  vomiting  and  local 
limitation  of  the  pains,  may  render  differential  diagnosis  from  chole- 
lithiasis, appendicitis,  etc.,  rather  difficult. 

2.  Hematuria  and  other  urinary  findings. 

Large  admixtures  of  blood  to  the  urine  are  not  seldom  met  with  in 
connection  with  new  formations  of  the  kidneys,  and  are  explained  in 
part  by  the  abundance  of  blood-vessels  in  the  tumors  (hj^pernephromas  !) 
and  their  soft  consistence.  A  prerequisite  in  most  cases  is  invasion  of 
the  pelvis  of  the  kidney. 

">'  See  Case  1. 

^■^P.  Albrecht,  Beitrage  ziir  Klinik  und  pathologisch.  Anatomie  der  malignen  Hy- 
pernephrome.     Arch.  f.  Klin.  Chir.,  Vol.  77,  No.  4. 
"'a  See  Case  1. 


MALIGNANT    TUMORS    OF    THE    KIDNEY  155 

Every  severe  renal  hemorrhage,  therefore,  must  remind  us  of  the 
possibility  of  a  malignant  process. 

"Renal"  Hematuria 

The  question  is:  How  can  the  renal  origin  of  tlie  hemorrhage  be 
recognized? 

The  most  exact  way,  probably,  is  by  separate  catheterization  of  the 
ureters. 

Of  diagnostic  value  also  are  thin  and  long  worm-shaped  blood-clots 
representing  casts  of  a  ureter,  combined  with  synchronously  occurring 
unilateral  ureteral  colics.  These  two  premises  admit  of  conclusions 
which  are  just  as  certain  as  ureteral  catheterization,  and  besides  may  be 
confirmed  by  the  previous  history. 

Certainly  one  will  also  think  of  a  renal  hemorrhage  when  the  admix- 
tures of  blood  appear  after  a  somewhat  brisk  palpation  of  a  kidney  tumor 
or  the  resistance  suspected  of  being  such. 

There  are  cases  in  which  it  is  even  advisable  to  cautiously  question 
the  patient  along  these  lines. 

Also  strong  contraction  of  the  belly-wall,  such  as  straining  at  stool, 
may,  by  way  of  venous  abdominal  stasis,  lead  to  severe  hemorrhages. 

On  the  other  hand,  profuse  renal  hemorrhages  from  renal  tumors, 
similar  to  the  hemoptysis  of  tuberculars,  are  more  or  less  incalculable ; 
they  ma}'  set  in,  pass  by  rapidly,  and  be  repeated  sometimes  only  after 
many  months  or  years. 

^Microscopically,  these  hemorrhages  behave  no  different  than  vesical 
hemorrhages :  The  erythrocytes  are  mostly  unchanged,  not  reduced  to 
shadows. 

"Occult"  Renal  Hemorrhage 

Comparable  to  the  "occult"  hemorrhages  occurring  with  gastro- 
intestinal carcinoma,  the  quantities  of  blood  mixed  with  the  urine  in  cases 
of  renal  neoplasms  may  be  so  small  that  they  escape  detection  with  the 
naked  eye.  The  urine  may  be  clear,  transparent,  even  surprisingly 
light. 

If  there  be  at  hand  other  indications  of  a  renal  neoplasm,  such  urinary 
findings  must  under  no  circumstances  be  used  as  a  ground  for  exclusion. 
Moreover,  if  an  effort  be  made  to  obtain  a  sediment  from  such  macro- 
scopically  unsuspicious  urine,  it  Avill  not  seldom  be  possible  to  demon- 
strate the  presence  of  erythrocyte  shadows. 

These  slight  hemorrhages  are  very  likely  not  to  be  explained  in  the 
way  of  blood-vessel  erosion,  but  rather  as  parenchymatous  bleedings. 
They  may  come  about  partly  through  congestion  or  capillary  tears,  but 
may  also  be  partly  due  to  inflammatory  alterations  in  the  neighboring 
renal  tissue.  Hence  also  we  are  here  dealing  mostly  with  erythrocyte 
shadows,  a  finding  which  in  and  of  itself  speaks  for  their  renal  origin. 
The  liberated  blood-coloring  material,  ingested  by  leucocytes,  may  occa- 
sionally be  eliminated  as  crystals  of  hematoidin. 


156  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Nephritic  Sedimentary  Findings 

On  the  other  hand  the  erythrocytes  may  occasionally  show  a  cylin- 
drical arrangement,  which  is  a  further  mark  of  their  renal  origin.  Even 
other  nephritic  sedimentary  findings  may  occur  in  connection  with  renal 
neoplasms,  though  we  need  not  necessarily  be  dealing  with  a  nephritis  in 
a  clinical  sense.  At  times  there  are  present  only  partially  inflamed  areas 
in  the  proximity  of  the  malignant  tissue  process. 

With  reference  to  typical  polymorphous  epithelia  which  are  at  times 
present,  I.  Israel  ^^^  admonishes,  and  rightly  so,  to  greatest  precaution. 
It  seems  that  tumor-tissues  are  cast  off  only  in  the  rarest  cases  (Case  6). 

Classified  in  the  order  of  importance,  the  newer  methods  of  "func- 
tional kidney  tests"  come  considerably  after  palpatory  examination  of 
the  kidneys  and  the  urinary  findings  just  discussed. 

Valuable  as  is  catheterization  of  the  ureters  in  order  to  test  sepa- 
rately the  urine  from  each  kidney  for  formative  elements,  blood-coloring 
material  and  albumin,  just  so  uncertain  are  the  conclusions  based  on 
methods  like  the  phloridzin-mcthylcne  blue  test,  cryoscopic  examina- 
tion, etc. 


PHYSICAL   EXAMINATION   OF    THE    KIDNEYS 

Much  would  be  gained  for  the  early  diagnosis  of  renal  neoplasms  if 
it  were  to  become  customary  to  attempt  palpation  of  the  kidneys  with  at 
least  every  initial  examination  of  the  abdomen. 

It  is  a  fact  that  with  reference  to  examination  by  palpation  the  kid- 
ney counts  among  the  most  neglected  organs,  so  much  so  that  even  when 
the  organ  is  in  a  diseased  condition,  e.g.,  nephritis,  hardly  any  effort  is 
made  at  palpation.  The  psychological  explanation  for  this  lies  in  the 
fact  that  the  effort  at  palpation  is  unsuccessful  in  a  large  percentage  of 
cases,  particularly  in  so  far  as  we  are  dealing  with  individuals  having  a 
deep  abdomen  and  without  enteroptosis. 

With  neoplastic  diseases  of  the  kidney  the  conditions  are  naturally 
far  more  favorable,  and  it  is  therefore  a  self-evident  requirement,  but 
which  I  consider  worthy  of  repeated  emphasis :  With  every  initial  ab- 
dominal examination  the  effort  must  be  made  to  palpate  the  kidneys. 

Where  the  findings  on  palpation,  though  obscure,  are  suspicious,  it 
will  occasionally  be  necessary  first  to  prepare  the  patient  for  examina- 
tion.i'^^ 

Artificial   Dislocation    of   the 
Kidney  Doivnicard 

As  enlarged  kidneys  are  most  often  abnormally  movable,  it  may  be  to 
the  point  to  let  the  patient  spring  from  a  foot-stool  in  order  to  dislocate 
the  kidney  downward.     For  the  same  purpose  it  will  be  advisable  to  have 

'"'Z.  Israel,  Chirurgische  Klinik  der   Nierenkrankheiten.     Aug.   Hirschwald,  1901. 
^"*  See  page  1. 


MALIGNANT    TUMORS    OF    THE    KIDNEY  157 

the   patient    breathe    purely    diaphragniatically    in    order    to    obtain    the 
greatest  possible  downward  displacement  of  the  kidney. 

Respiratory  Mobility 

It  is  decidedly  erroneous  to  refer  to  kidney  tumors  as  not  having 
respiratory  mobility.  The  respiratory  mobility  of  large  kidne^'-tumors, 
e.g.,  congenital  cystic  kidneys,  may  occasionally  be  determined  by  mere 
inspection. 

Lateral  Decuhitus 

In  order  to  relax  the  belly-wall  on  the  side  aflfected,  it  may  be  ad- 
visable to  make  an  examination  with  the  patient  lying  partly  or  entirely 
on  his  side  {Israel,  I.e.). 

It  should  always  be  our  endeavor  to  diminish  the  sagittal  depth  of 
the  abdomen  by  means  of  broad  and  effective  counterpressure  from  the 
respective  lumbar  region,  so  that  the  kidney,  which  may  be  considered  as 
lying  at  the  bottom  of  the  abdomen,  may  be  better  reached  from  in  front. 

Ballottement 

In  this  connection  I  would  not  attach  any  particular  diagnostic  sig- 
nificance to  the  possibility  of  bringing  a  tumor  which  can  be  felt  an- 
teriorly nearer  to  the  palpating  hand  by  pressure  in  the  loin,  that  is, 
ballottement. 

Larger  tumors  of  the  spleen,  being  in  contact  with  the  lumbar  region, 
show  this  symptom  almost  regularly ;  the  same  is  true  of  "corset  lobes'* 
of  the  liver.  In  this  case,  however,  the  pressure  is  more  effective  if  made 
laterally  on  the  right  side  and  in  a  forward  direction  than  directly  from 
the  back  on  the  same  side,  because  the  "corset  lobe"  is  more  intimately 
in  contact  with  the  belly-wall  in  the  axillary  portions  than  it  is  in  the 
paravertebral  area. 

In  very  exceptional  cases  even  tumor-masses  belonging  to  the  stom- 
ach, providing  they  be  situated  on  the  left  side  below  the  costal  arch, 
may  show  ballottement.  Naturally,  the  ballottement  will  here  depend 
upon  the  relation  of  the  tumor-mass  to  the  lumbar  region. 

A  kidney  tumor  which  exhibits  this  phenomenon  in  the  dorsal  de- 
cubitus may  not  do  so  at  all  in  the  lateral  decubitus. ^"^'^ 

Situation  of  the  Colon  and  Its 
Determination 

As  in  the  case  of  ballottement,  I  would  not  attach  too  much  im- 
portance to  the  position  of  the  colon  with  reference  to  its  relation  to  a 
questionable  tumor-mass. 

Even  though  a  kidney  tumor,  as  compared  to  splenic  tumors,  gen- 
erally has  the  colon  anterior  to  it,  there  are  many  and  varied  exceptions. 
Very  frequently  the  patient  can  be  spared  the  annoyance  of  a  distention 
of  the  colon ;  the  same  should  always  be  omitted  when  there  is  any  sus- 
picion of  an  ulcerous  gastric  or  intestinal  lesion,  as  it  is  not  without  dan- 
ger under  such  circumstances  (hemorrhage!  perforation!). 

"^  See  Case  2. 


158  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Intestine  overlying  the  tumor-mass  anteriorly  will  occasionally  be 
recognizable  by  the  fact  that  one  can  roll  a  cylindrical  structure  (con- 
tracted coil  of  intestine)  to  and  fro  on  the  surface  of  the  tumor.  If, 
however,  the  portion  of  bowel  lying  in  front  of  the  tumor  is  sponta- 
neously distended,  palpation  will  disclose  that  in  this  region  the  tumor  is 
not  adjacent  to  the  abdominal  wall,  and  there  will  be  present  splashing 
sounds  or  local  spontaneous  bowel  noises. 

Peritoneal  friction  over  a  tumor-mass  always  indicates  direct  con- 
tact with  the  parietal  layer  of  the  peritoneum,  hence  excludes  anterior  in- 
terposition of  intestine. 

Diiferentiation  from   Gall-Bladder 
and  Splenic  Tumors 

One  should  always  try  to  see  whether  it  is  possible  in  some  position 
or  other  to  grasp  the  tumor  from  above,  as  this  excludes  the  possibility 
of  gall-bladder  and  splenic  tumors. 

Soft  Consistence 

In  palpating  enlargements  of  the  kidney  it  will  be  well  to  bear  in 
mind  that  malignant  tumors  of  the  kidneys,  and  this  is  particularly 
true  of  the  most  frequent  species,  i.e.,  hypernephromas,  very  often  are 
of  a  soft,  elastic  consistence  on  account  of  their  abundance  of  blood- 
vessels, which  is  frequently  also  seen  in  the  metastases  from  it,  e.g.,  in 
the  liver. 

Hardness  and  nodular  outline,  which  are  otherwise  such  frequent 
attributes  of  malignant  tumor  formations,  are  here  met  with  compara- 
tively seldom. 

Auscultatory  Findings 

The  abundance  of  blood-vessels  in  a  hypernephroma  justifies  the 
assumption  that  an  auscultatory  phenomenon  should  occur  more  fre- 
quently than  would  be  surmised  from  reports  hitherto  made  by  observers 
who  probably  paid  no  attention  to  it. 

This  is  a  loud-blowing  systolic  murmur,  as  it,  for  instance,  was  audible 
in  Case  3,  especially  in  the  flanks. 

It  will  be  advisable  to  look  for  it,  not  only  anteriorly  but  also  in  the 
lumbar  region  and  in  the  flanks. 

ACCOMPANYING    SYMPTOMS    FROM    OTHER    ORGANS 

In  view  of  the  great  frequency  of  hypernephromas  and  their  ten- 
dency to  the  formation  of  bone  metastases,  every  enlargement  of  the 
kidney  ought  to  lead  to  a  careful  examination  of  the  skeletal  system, 
but  reversely  also  a  spontaneous  fracture,  a  bone  tumor  would  be  the 
occasion  for  a  most  careful  examination  of  the  kidneys  and  urine. 

The  vault  of  the  cranium,  femur,  clavicle,  scapula,  rib,  etc.,  may  in 
a  similar  manner  become  the  seat  of  metastases,  which,  in  accord  with 
their  abundant  supply  of  blood-vessels,  occasionally  exhibit  definite 
pulsation. 


MALIGNANT    TUMORS    OF    THE    KIDNEY  159 

Early  Metastases 

P.  Alhrecht  ^^^  has  called  particular  attention  to  the  occurrence  of 
singular  hone  metastases,  surgical  removal  of  which  was  followed  hy  rela- 
tively good  health  often  for  many  years  (6Vi>  years  in  one  of  his  cases). 

Here,  then,  we  occasionally  have  to  deal  with  the  very  exceptional 
case  in  which  operation  is  indicated  for  removal  of  a  metastatic  growth. 

Late  Metastases 

On  the  other  hand,  the  danger  of  bone  metastases  remains  present  for 
many  years  after  the  successful  removal  of  a  hypernephroma  of  the 
kidney. 

Thus  in  one  of  the  cases  of  the  author  just  cited,  there  occurred  a 
metastasis  in  the  vertebral  column  as  late  as  seven  years  after. 

The  formation  of  metastases  probably  occurs  chiefly  by  way  of  the 
blood-current,  a  predisposing  factor  being  the  frequent  penetration  of 
the  tumor-masses  into  the  renal  vein. 

Thus  occasionally  also  the  brain  may  become  the  seat  of  metastasis, ^*^''' 
and  not  rarely  there  are  metastases  in  the  lungs. 

I  recall  a  case  in  which  a  carcinoma  of  the  tongue  had  been  diagnosed; 
autopsy,  however,  disclosing  a  hypernephroma  as  the  primary  focus.  In 
Case  5  there  had  occurred  metastases  in  the  vaginal  wall  and  ulceration. 

All  of  these  secondary  tumor  formations,  in  so  far  as  we  are  dealing 
with  hypernephromas,  have  a  peculiar  soft  marrow-like  consistence,  a 
circumstance  which  itiay  render  diagnosis  difficult,  especially  in  the  region 
of  the  liver. 

Lymphogenous  Metastasis 

Propagation  by  way  of  the  lymph  current  is  probably  to  be  looked 
upon  as  a  rare  exception  to  the  rule  of  hematogenous  metastasis. 

In  this  regard  great  interest  attaches  to  Clairmonfs  ^"^  observation 
of  a  metastasis  in  the  bronchial  lymph-nodes,  causing  death  ten  years 
after  extirpation  of  a  hypernephroma. 

While  we  have  so  far  considered  chiefly  the  remote  symptoms  result- 
ing from  the  formation  of  metastasis,  we  must  also  remember  those  phe- 
nomena which  are  connected  with  the  local  spread  of  the  tumor-mass. 

Varicocele 

Here  belongs  the  occurrence  of  a  varicocele  as  occasionally  observed, 
especially  when  the  tumor  is  situated  on  the  left  side.  It  would  alwa^'s  be 
of  great  importance  to  determine  from  the  history  or  by  observation 
how  rapidly  it  develops.  Since  various  cases  of  renal  tumors,  whose  rela- 
tion to  the  renal  vein  and  internal  spermatic  vein  are  similar,  are  not 
characterized  by  the  occurrence  of  a  varicocele,  the  assumption  is  close 
at  hand  that  a  certain  predisposition  on  the  part  of  the  venous  plexus 
is  required  to  produce  this  condition. 

'"*  Arch.  "f.  klin.  Chir.,  1905,  Vol.  77,  No.  4. 

'"■  See  Case  5. 

^'*f.  Clairmont.     Verhaiidl.  des  32  Kongr.  d.  deiitsch.     Ges.  f.  Chir.,  1903,  p.  196. 


160  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Bladder  Symptoms 

Bladder  symptoms,  such  as  retention  of  urine  or  tenesmus,  arc  prob- 
ably to  be  looked  upon  partly  as  reflex  symptoms,  as  they  may  also  be  ob- 
served in  connection  with  acutely  occurring  infarcts  of  the  kidney  ("renal 
dysuria"). 

Stomach 

The  violent  appearance  of  gastric  symptoms,  such  as  vomiting,  epi- 
gastric sensation  of  pressure,  anorexia  for  meat,  etc.,  may  at  times  be 
misleading.  Partly  also  these  sjmiptoms  are  to  be  interpreted  as  reflex 
processes,  particularly  the  vomiting,  just  as  it  accompanies  ureteral 
colics.^"'*  The  symptoms  may  also  have  their  origin  in  the  general 
cachexia,  or  may  be  traced  to  pressure  exerted  by  the  tumor-mass.  In 
case  of  bilateral  disease  they  might  also  be  due  to  uremia. 

Fever 

Chills  have  occasionally  been  observed  during  the  course  of  renal  neo- 
plasms ;  one  would  incline  to  connect  them  with  complicating  pyelitis. 

Thrombus  formation  in  the  renal  veins  and  the  inferior  vena  cava, 
hence  phlebitic  complication,  will  also  have  to  be  thought  of. 

According  to  Israel  (I.e.),  febrile  accompanying  manifestations  be- 
cloud the  prognosis  of  operative  interference. 


COURSE,   DURATION,   TYPES 

Whilst  a  large  proportion  of  the  disease  symptoms  produced  by 
malignant  new  formations  in  the  chylo-poetic  system  are  due  to  the  severe 
injury  to  the  digestive  mechanism,  malignant  diseases  of  the  kidneys 
aff'ord  an  opportunity  to  determine  the  effects  of  malignant  tumors  as 
such  on  the  organism. 

Numerous  observations  are  at  hand  which  would  make  malignant  new 
formations  of  the  kidney — and  this  seems  particularly  true  of  the  fre- 
quently occurring  tumors  of  Grawitz — appear  comparatively  benign,  at 
least  so  far  as  the  duration  of  the  disease  is  concerned. 

A  very  striking  illustration  of  this  fact  is  the  case  of  P.  Albrecht, 
already  cited,  in  which,  the  primary  tumor  remaining,  the  patient  was 
alive  61/^  years  after  successful  surgical  removal  of  a  metastatic  bone 
formation,  and  then  came  to  autopsy,  which  showed  a  kidne^^-tumor  of 
Grawitz  and  multiple  metastases. 

Although  other  observers  have  repeatedly  reported  cases  with  a  dura- 
tion of  ten  years  and  longer,  they  are  probably  cases  in  which  loss  of 
blood  through  hematuria  occurred  either  not  at  all  or  only  shortly  before 
death. 

If  hematuria  sets  in,  the  prognosis  as  to  the  duration  of  life,  provid- 
ing the  surgeon  does  not  promptly  interfere,  is  decidedly  unfavorable. 

.      '""See  Case  1. 


MALIGNANT    TUMORS    OF    THE    KIDNEY  161 

The  same  holds  good  also  of  the  relatively  frequent  renal  neoplasms 
of  children,^ ^*'  even  though,  as  is  the  rule,  hematuria  is  ahsent.  Here 
tile  average  duration  of  the  disease  seems  to  be  onU'  seven  to  eight 
months. 

Other  things  being  equal,  the  malignant  renal  neoplasms  of  adults 
probably  admit  of  a  far  better  prognosis. 

In  these  cases  there  may  even  be  observed,  during  the  course  of  the 
disease,  quite  appreciable  gains  in  weight.^ ^^ 

Late  metastases  seem  to  be  a  peculiarity  of  hypernephromas,  which 
casts  a  gloom  on  the  prognosis  even  after  successful  extirpation  of  the 
primary  focus. 

The  metastatic  deposits  may  be  latent  for  many  years  and  only  then 
awaken  to  malignant  growth. 

Here  we  may  again  call  attention  to  P.  Chiirmont's  interesting  obser- 
vation, in  which  ten  years  after  extirpation  of  the  kidney  death  occurred, 
due  to  metastatic  proliferation  in  the  bronchial  lymph-nodes. 

For  the  clinician  there  are  two  main  types  of  malignant  renal  neo- 
plasms, and  they  arc : 

1.  The  "infantile"  renal  neoplasms,  w^hich  counts  among  the  most 
important  and  most  convincing  arguments  in  favor  of  Colinlieim''s  tumor 
theory,  as  it  is  observed  even  in  the  new-bom,  and  in  its  entire  structure 
(striped  muscle  fibres,  cartilaginous  and  osseous  tissue)  exhibits  the  fetal 
predispositioji  (Anlage).  It  makes  its  appearance  in  the  first  ^-ears  of 
life  and  may  appear  up  to  the  end  of  the  first  decade. 

Its  characteristics  are:  enormous  growth,  slight  tendency  to  forma- 
tion of  metastases,  hematuria  rare,  rapid  course. 

2.  Tumor  of  Grawitz  ("hypernephroma").  Being  by  far  the  most 
frequent  of  renal  neoplasms,  this  also  is  a  crown  witness  in  favor  of  Cohn- 
lieitns  tumor  theory. 

Its  characteristics  are:  tendency  to  hematuria  ;  in  the  absence  of  hema- 
turia relative  benignancy,  with  a  course  at  times  extending  over  many 
years;  occasional  absence  of  cachexia,  good  appearance;  tendency  to 
singular  and  at  times  pulsating  bone  metastases,  late  metastases. 


SUSPICIOUS    FACTORS    AND    DIFFERENTIAL    DIAGNOSIS 

Prevalence  in  the  Male  Sex 

.  Other  things  being  equal,  factors  of  suspicion  will  carry  more  weight 
in  male  individuals ;  for  statistics  agree  that  malignant  processes,  in 
striking  contrast  to  tuberculosis  of  the  kidneys,  are  far  more  frequent  in 
the  male  sex. 

Given  the  four  fundamentals  in  the  diagnosis  of  malignant  processes 
in  general,  i.e.,  tumor,  hemorrhage,  cachexia,  pain,  it  will  in  most  in- 
stances not  be  difficult  to  draw  the  proper  conclusion. 

""  T.  Oshima.     Wiener  klin.  Wochenschr.,  190",  No.  4. 
"'  See  Cases  3  and  4. 


162  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Difficulties  arise  when  one  of  these  premises  is  more  prominently 
realized.  Having  correctly  recognized  a  hematuria  with  reference  to  its 
renal  origin  and  its  source  from  one  kidney,  and  dealing  with  a  profuse 
hemorrhage,  the  chief  conditions  entering  into  differential  diagnosis  will 
be  nephrolithiasis,  tuberculosis  of  the  papillae  of  the  kidneys  and — in  the 
order  of  frequency  after  a  long  interval  only — "parenchymatous"  ^^- 
hematuria. 

The  discharge  of  blood-clots  and  clot  formation  in  the  urine  generally 
indicates  hemorrhage  from  erosion  and  makes  a  "parenchymatous"  hem- 
orrhage improbable. 

"Parenchymatous"   Unilateral  Belial 
Hemorrhage 

"Parenchymatous"  unilateral  renal  hemorrhages  generally  also  dis- 
tinguish themselves  by  their  constancy  and  uniformity  as  opposed  to  the 
often  rapidly  arrested  hemorrhages  from  erosion. 

The  pain  phenomena,  such  as  ureteral  colic,  may  be  entirely  identical 
in  connection  with  profuse  hemorrhages  resulting  from  tuberculosis  of 
the  papilla'  of  the  kidneys,  neoplasm  and  nephrolithiasis ;  even  unilateral 
"parenchymatous"  renal  hemorrhages  may — probably  as  a  result  of  acute 
congestion  of  the  respective  kidney — be  accompanied  by  violent  uni- 
lateral pains,  but  it  seems  that  a  painless  course  is  far  more  frequently 
the  case  in  these  instances. 

N  ephrolithiasis 
Renal   Tuberculosis 

Hemorrhage  in  nephrolithiasis,  for  that  matter,  seldom  becomes  se- 
vere, and  just  as  little  do  profuse  hemorrhages  in  connection  with  tuber- 
culosis of  the  renal  papilhe  count  among  the  frequent  occurrences,  yet 
they  may  occasionally  appear  clinically  as  an  early  symptom,  unaccom- 
panied by  pyuria. 

It  is  remarkable  that — quite  analogous  to  conditions  in  the  lung — 
slight,  easily  overlooked  tuberculous  alterations  in  the  renal  papillas 
may  lead  to  severe  hematuria,  whilst  extensive  destructions  of  the  same 
kind  may  go  along  without  hemorrhage. 

Painless  renal  hemorrhage  would  generally  speak  against  nephro- 
lithiasis, though  rare  exceptions  may  occur  even  here ;  if  the  calculus 
remains  stationary  in  one  place  and  through  pressure  necrosis  leads  to 
erosion  of  a  blood-vessel,  then  we  have  the  exceptional  case  just  re- 
ferred to. 


"^  It  is  not  within  the  scope  of  this  treatise  at  this  juncture  to  tatce  part  in  the  dis- 
pute about  "essential"  unilateral  renal  hemorrhage  from  a  "healthy  kidney."  In  a  great 
number  of  cases  in  which  a  pathological  and  anatomical  examination  was  made — and 
only  such  can  be  admitted  as  evidence — inflammatory  alterations  were  demonstrated. 
It  is  true  they  were  so  slight  that  it  may  be  doubtful  wliether  they  explain  the  profuse 
hematuria  in  Individual  cases.  Undoubtedly  we  are  here  not  dealing  with  hemorrhages 
due  to  erosion,  but  rather  with  "parenchymatous"  hemorrhages,  and  it  seems  to  me 
that  this  contrast,  with  stress  on  the  "onesidedness,"  is  more  important  than  the  unpro- 
ductive discussion  as  to  genesis. 


MALIGNANT    TUMORS    OF    THE    KIDNEY  163 

Systolic   Vascular  Murmurs 

Attention  should  always  be  given  to  systolic  vascular  murmurs  in  the 
region  of  the  kidneys.  When  these  can  be  referred  to  the  kidneys  they 
will,  in  the  first  place,  make  us  think  of  malignant  renal  disease. 

Findings  on  Palpation 

Neoplasms  of  the  kidneys  accompanied  by  hemorrhage  will  probably 
in  most  cases  yield  positive  findings  on  palpation,  and  it  will  be  well  to 
look  for  nodular  prominences  on  the  surface  of  the  kidneys ;  if  only  small 
areas  of  the  kidney  are  involved  or  if  they  are  situated  in  the  upper  pole 
of  the  kidney,  every  objective  finding  naturally  may  be  absent. 

There  is  some  danger  that  the  low  situation  of  the  inferior  pole  of 
the  kidney  may  be  considered  harmless  in  those  cases  where  the  low  situa- 
tion is  in  reality  due  to  increase  in  the  long  diameter,  be  it  that  this  in- 
crease has  taken  place   at   the  superior  or  inferior  pole  of  the  kidney. 

In  such  cases — if  there  be  tumor  formation  in  the  lower  pole  of  the 
kidney — the  particular  ease  with  which  ballottement  can  be  elicited  might 
call  attention  to  the  increased  antero-posterior  diameter  of  the  appar- 
ently intact  pole  of  the  kidney  (/.  Israel,  I.e.). 

When  the  findings  on  palpation  are  entirely  negative,  local  pains  in 
the  region  of  the  kidney,  accompanied  by  bone  metastases,  might  lead 
one  onto  the  right  track. 

Bone  Tumors 

Malignant  bone  tumors  ought,  under  all  circumstances,  to  suggest 
the  possibility  particularly  of  renal  tumors  of  Grawitz.  In  these  cases 
most  careful  microscopical  examination  of  the  urinary  sediment  will  be 
indicated  even  though  the  macroscopic  findings  are  entirely  unsuspicious. 

Nephritis 

Occasionally  w,e  meet  with  nephritic  sedimentary  findings,  such  as 
blood-casts,  waxy  casts,  etc.,  derived  from  inflamed  portions  of  the  kid- 
ney-tissue in  the  immediate  proximity  of  the  tumor-mass. 

Splenic  Tumor 

Kidney  tumors  on  the  left  side  will  occasionally  have  to  be  differen- 
tiated from  the  larger  splenic  tumors.  Pronounced  diminution  of  the 
leucocyte  count  would  speak  in  favor  of  a  splenic  tumor,  as  pseudoleu- 
kemia, for  instance,  and  Banti's  cirrhosis  are  most  often  accompanied  by 
leucopenia.  The  constant  findings  of  a  strongly  positive  aldehyde  reac- 
tion would  have  to  be  construed  in  the  same  way.  The  physical  findings 
are  by  no  means  always  sufficient  for  a  differentiation.  If  it  is  possible 
in  any  position  to  grasp  the  tumor  from  above,  then  we  have  a  weighty 
argument  against  the  assumption  of  a  splenic  tumor. 

Sarcomas  originating  retroperitoneally  and  in  the  immediate  neigh- 
borhood of  the  kidne}'^,  also  pararenal  embryonic  tumors,  may  imitate 
kidney  tumors  in  all  the  physical  details ;  the  same  is  occasionally  true  of 
echinococcus  cysts. 

The  differentiation  from  suprarenal  tumors  and  the  so-called  "para- 


164  TUMORS    OF    THE    ABDOMINAL    VISCERA 

renal"  tumor  forms  (from  rests  of  the  Wolffian  bodies  or  displaced  su- 
prarenal tissue)   may  encounter  the  greatest  difficulty. 

Suprarenal  Tumor 

According  to  Israel,^^^  also  suprarenal  tumors  situated  outside  of 
the  kidney  as  well  as  hypernephromas  may  lead  to  hematuria  through  cir- 
culatory disturbances  in  the  inferior  vena  cava  and  renal  vein. 

Analogous  to  renal  tumors,  they  can  be  felt  underneath  the  costal 
arch,  but  generally  occupy  a  more  median  situation ;  they  are  said  to  lead 
to  prolonged  neuralgias  in  the  lumbar  plexus  earlier  than  h^^pernephro- 
mas.  Israel  has  noted  atypical  febrile  movements  surprisingly  often  in 
his  nine  observations,  and  only  in  one  case  was  there  Addison-like  pigmen- 
tation. 

If  the  tumor  is  recognized  as  belonging  to  the  kidney,  the  field  of  dif- 
ferential diagnosis  is  not  a  large  one. 

Pyonephrosis 

Pyonephroses,  if  they  be  open,  are  easily  excluded  by  the  demonstra- 
tion of  pyuria,  which  occurs  practically  never  in  connection  with  malig- 
nant neoplasms  of  the  kidneys.  The  demonstration  of  a  renal  enlarge- 
ment in  the  absence  of  secretion  from  the  respective  ureter  (ureteral 
catheterization)  would  generall}'^  speak  against  a  renal  neoplasm  and  in 
favor  of  a  closed  hydro-  or  pyonephrosis. 

Cystic  Kidney 

Congenital  cystic  kidneys,  met  with  also  in  later  life  in  the  form  of 
large  nodulated  tumor-masses,  are  generally  characterized  by  their  bi- 
lateral occurrence. 

It  remains  to  be  mentioned  that  particularly  in  the  case  of  non-bleed- 
ing renal  neoplasms — especially  hypernephromas — even  in  the  stage  of 
metastasis  formation,  cachexia  does  not  count  among  the  integral  com- 
ponent parts  of  the  symptom  complex. 

"'/.  Israel,  Zur  Diagnose  der  Nebennierengeschwiilste.  Deutsche  med.  Wochenschr., 
1905,  No.  44. 


"Atypical"  Malignant  Abdominal  Tumors 


Practical  considerations  have  prompted  me  to  add  this  section. 

It  is  advisable  to  separate  in  one's  memory  the  frequent  from  the 
rare,  keeping  in  mind  the  scale  of  frequency  for  the  purpose  of  arriving 
at  a  clear  differential  diagnosis ;  this  requisite  should  also  receive  consid- 
eration in  descriptive  treatises. 

Only  if  after  a  detailed  diagnostic  analysis  of  the  individual  case 
reasons  present  themselves  which  speak  against  the  assumption  of  one 
of  the  hitherto  discussed  "typical"  kinds  of  neoplasms,  arc  there  indica- 
tions for  thinking  of  the  rare  possibilities  here  to  be  touched  upon,  whose 
range  naturally  cannot  be  defined. 

Sarcoma 

The  rarity  may  have  some  connection  with  the  histological  structure 
of  the  tumor  (sarcoma!). 

So  far  as  glandular  enlargements,  splenic  neoplasms  and  new  forma- 
tions of  the  small  intestine  are  concerned,  it  will  occasionally  be  possible 
clinically  to  make  the  diagnosis  of  sarcoma. 

Spleen 

If,  for  example,  in  view  of  the  cachexia,  the  nodular  structure,  the 
rapid  growth  at  times  accompanied  by  severe  pains  and  a  blood-count  ex- 
cluding leukemia,  we  are  able  to  make  the  diagnosis  of  a  malignant  tumor 
of  the  spleen,  there  results  from  the  pathological  anatomy  quite  auto- 
matically the  diagnosis  of  sarcoma. 

Retroperitoneal  Glands 

The  same  is  true  of  those  cases  in  which  the  conclusion  has  been  ar- 
rived at  that  the  malignant  process  takes  its  origin  from  the  retroperi- 
toneal glands  (5)  or  the  lymphatic  sj^stem  in  general. 

If  sarcomatous  tumors  develop  along  the  gastro-intestinal  tract — 
and  l^'mpho-sarcomas  are  first  to  be  considered — the  decision  whether  it 
is  a  sarcoma  or  a  carcinoma  is  practically  beyond  the  pale  of  diagnostic 
possibilities. 

Lymphosarcoma  and   Constitution 

So  far  as  l^'mphosarcomas  are  concerned,  it  seems  to  me  important 
not  to  leave  constitutional  factors  unheeded. 

The   existence   of   a    congenital    factor    such    as    status    l^'-mphaticus, 

status  hypoplasticus  and  status  thymicus  would  always  have  to  be  taken 

into   consideration,  and  symptoms   such  as  hyperplasia  of  the  external 

glands,  the  follicles  of  the  base  of  the  tongue  (Kundrat),  scrofulous  ante- 

165 


166  TUMORS    OF    THE    ABDOMINAL    VISCERA 

cedents  with  homologous  diseases  of  the  eyes  may  suggest  the  presence 
of  a  lymphosarcomatous  process.  As  tuberculosis  frequently  develops  in 
individuals  with  similar  congenital  predisposition,  it  cannot  be  surpris- 
ing that  not  infrequently  there  is  actually  a  coincidence  of  lympho- 
sarcoma and  tuberculosis.  It  is  even  possible  that  the  tubercle  bacillus^ 
through  its  local  presence  or  by  way  of  tuberculous  dyscrasia,  occasion- 
ally furnishes  an  impulse  to  the  development  of  lymphosarcomatous 
processes. 

It  seems  to  me  that  we  are  here  concerned  chiefly  with  individuals  in 
whose  cases  it  is  the  Ij^iiphatic  system  rather  than  the  pulmonary  that 
reacts  to  tuberculosis,  so  that  florid  pulmonary  tuberculosis  is  hardly 
ever  observed,  not  rarely,  however,  glandular  tuberculosis  and  healed  or 
stationary  pulmonary  foci. 

Accordingly,  we  are  frequently  dealing  with  individuals  having  a  pale 
facial  color,  reddish  blond  hair,'^^  paralytic  thorax,  and  at  times  an  en- 
teroptotic  abdomen.  It  seems  that  not  seldom  relatively  young  persons 
in  the  thirties  and  forties  are  afflicted  with  lymphosarcomatous  processes. 

Among  the  very  rare  sarcomatous  diseases  occurring  within  the  chylo- 
poetic  system  lymphosarcomatosis  of  the  small  intestine  is  most  apt  to 
admit  of  diagnosis. ^^''^  Here,  in  striking  contrast  to  all  other  localities, 
lymphosarcomas  are  nmch  more  frequent  than  carcinomas,  so  that  when 
the  presence  of  a  malignant  disease  in  the  small  intestine  has  been  estab- 
lished it  makes  a  lymphosarcoma  very  probable.  In  view  of  what  has 
been  previously  said  in  regard  to  congenital  anomalies,  the  assumption — 
corroborated  in  practice — is  close  to  hand  that  especially  tubercular  dis- 
eases, such  as  tubercular  peritonitis  and  tubercular  intestinal  ulcers,  will 
enter  into  differential  diagnostic  consideration.  It  is  worthy  of  note  that 
ascites  in  connection  with  lymphosarcomatosis  of  the  small  intestine  does 
not,  as  in  peritoneal  tuberculosis,  occur  more  or  less  isolated,  but  is  in 
most  instances  a  partial  manifestation  of  a  general  edema  and  dropsy 
of  the  serous  cavities.  Diagnosis  is  very  much  hampered  by  the  fact  that 
as  a  result  of  the  rather  diffuse  infiltration,  often  extending  over  wide 
areas  of  the  intestine,  circumscribed  tunior-masses  are  frequently  absent, 
in  addition  to  which  meteorism  and  ascites  often  act  as  obstacles  in  the 
way  of  palpation.  If  tumor-masses  can  be  felt,  their  soft  consistence 
might  occasionally,  even  though  conditionally  only,  be  interpreted  as 
speaking  against  carcinoma.  The  tendency  to  diffuse  infiltration  of  the 
walls  and  the  soft  consistence  of  the  tumor-mass  probably  account  for 
the  fact  that  lymphosarcoma  of  the  small  intestine,  in  contradistinction 
to  scirrhus  carcinoma  of  the  small  bowel,  does  not,  as  already  pointed  out 
by  Kundrat,  produce  stenosis,^ ^"  on  the  contrary,  even  causes  dilatation 

"^  So  far  as  the  clinical  material  available  in  Vienna  is  concerned,  I  have  found 
that  individuals  with  a  congenital  tendency  to  tuberculosis  not  rarely  are  characterized 
by  «i  dark-brown  head  of  hair  whilst  the  mustache  is  of  a  foxy-red  color  ("hair  dis- 
harmony") ;  I  have  seen  this  peculiar  combination  very  often  with  tuberculosis  of  the 
peritoneum  and  also  in  connection  with  Ivmphosarcomatous  processes. 

"=See  Cases  9,  10,  11. 

"*  Case  9  illustrates  that  adhesion  and  coalescence  of  adjacent  intestinal  loops  maj^ 
lead  to  severe  stenosis. 


"ATYPICAL"    MALIGNANT    ABDOMINAL    TUMORS       167 

of  the  intestinal  tube  in  the  diseased  area.  No  significance  attaches  to 
this  criterion  in  the  case  of  the  large  intestine,  because  there  even  carci- 
nomas, especially  the  easily  ulcerating  medullary  forms,  may  go  along 
without  stenosis. 

As  shoAvn  in  the  epicrisis  of  Case  11,  the  bacterial  growth  may  at 
times  become  an  important  diagnostic  criterion  in  lymphosarcoma  of  the 
small  intestine. 

The  increase  of  the  large  mononuclear  cells  of  the  blood  may  amount 
to  at  least  a  suspicious  factor  in  lymphosarcomatous  processes. 

Sarcoma  of  the  Stomach 

If,  in  connection  with  sarcomatous  processes  of  the  digestive  tract, 
reference  is  occasionally  made  to  the  slight  tendency  to  hemorrhage,  it 
would  seem  to  me  to  be  more  of  a  theoretical  postulate  based  on  the  sub- 
mucous origin  of  the  new-growth;  the  actual  fact  is  that  severe  ulcera- 
tion of  the  mucous  membrane  is  often  met  with.  Case  7  is  an  example 
of  a  fatal  gastric  hemorrhage  as  an  early  symptom  of  lymphosarcoma 
of  the  stomach. 

Splenic  tumors  also  are  to  be  interpreted  with  the  greatest  precau- 
tion ;  they  may  be  absent,  or  their  presence  in  connection  with  gastro- 
intestinal carcinoma  may  be  accounted  for  in  divers  ways  (anemia,  com- 
pression of  the  splenic  vein,  etc.). 

The  same  is  true  of  the  exorbitant  size  of  tumor-masses,  which  ac- 
tually applies,  for  instance,  to  some  gastric  sarcomas,  but  which  in  and  of 
itself  can  never  be  decisive. 

The  more  experience  one  gathers,  the  more  cautious  one  will  become 
in  these  decisions,  and  so  much  more  one  will  learn  to  respect  those  limits 
where  logical  recognition  ends  and  guessing  begins. 

"Atypical"  Localization 

Malignant  growths  of  the  abdominal  cavity  may  be  "atypical"  and 
rare  with  regard  also  to  their  localization. 

Diaphragmatic  Tumors 

Thus  I  recall  a  case  of  metastatic  sarcoma  of  the  left  pleura,  in  which 
a  nodular  tumor-mass  was  palpable  just  below  the  left  costal  arch.  In 
view  of  a  constant  strongly  positive  aldehyde  reaction,  liver  metastases 
were  thought  of.  Autopsy  showed  that  the  tumor-masses  belonged  to 
the  left  half  of  the  diaphragm,  which  had  been  forced  downward. 

Cancer  of   the   Small   Intestine 

Here  we  may  also  mention  the  decidedly  rare,  mostly  scirrhus  can- 
cers of  the  small  intestine;  as  they  are  not  palpable  on  account  of  the 
small  size  of  the  tumor,  a  certain  diagnosis  will  hardly  ever  be  made.  The 
combination  :  Severe  obstructive  symptoms  and  diarrheas  could  easily  lead 
one  to  think  that  the  stenosis  affects  a  portion  of  intestine  in  which  the 
contents,  on  account  of  their  fluid  character,  maj^  easily  pass  even  a 
stenosis  of  high  degree. 


168  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Duodenal  Cancer 

Carcinomatous  diseases  of  the  duodenum  ^^^  also  count  among  the 
relatively  rare  occurrences. 

Their  correct  recognition  during  life  is  beset  with  great  difficulties, 
arising  already  from  the  fact  that  frequently,  on  account  of  their  deep 
situation  or  their  small  size  (this  is  especially  true  of  the  periampullar 
forms),  a  tumor  cannot  be  felt. 

"Periampullar" 

If  in  spite  of  this  precisely  the  periampullar  forms  are  more  easily 
accessible  to  medical  diagnosis,  it  is  due  to  their  limited  topographical  re- 
lation to  the  terminal  portion  of  the  ductus  choledochus.  They  enter  into 
differential  diagnostic  consideration  in  every  case  of  "malignant"  icterus, 
in  regard  to  which  we  refer  to  previous  discussions.^^'*  A  large  gall- 
bladder, without  alterations  in  its  walls,  occult  intestinal  hemorrhage, 
pronounced  appearance  of  at  times  high  febrile  cholangitic  processes  with 
perihepatitis,  abscesses  of  the  liver,  etc.,  may  count  as  most  important 
attributes. 

"Parapyloric" 

"Prejejunal" 

The  high  up  parapyloric  and  low  down  prejejunal  duodenal  neo- 
plasms will  frequently  run  their  course  under  the  clinical  picture  of  a  car- 
cinoma of  the  pylorus.  At  the  same  time,  it  must  always  be  borne  in 
mind  that  there  are  far  more  chances  in  these  cases  for  the  persistence 
of  HCl  secretion;  also  that  in  the  prejejunal  forms  the  conditions  for 
regurgitation  of  bile  and  pancreatic  juice  into  the  stomach  are  more 
favorable.  Carcinoma  of  the  pylorus  is  only  very  exceptionally  accom- 
panied by  vomiting  of  bile ;  the  withdrawn  stomach  content  in  particular 
very  seldom  contains  bile-coloring  matter. 

Cancer  of  the  Appendix 

Malignant  tumors  of  the  appendix  ^^'* — carcinomas  come  into  first 
consideration — do  not  admit  of  diagnosis  on  account  of  their  small  size. 
As  apparently  they  do  not  lead  to  metastases  and  do  not  show  unlimited 
growth,  they  can  hardly  be  looked  upon  as  "malignant"  tumors  in  a  clin- 
ical sense,  even  though  they  bear  their  histological  characteristics. 

Omental  Tumors 

On  account  of  their  relative  rarity,  malignant  tumors  of  the  omen- 
tum ^-"  (almost  always  secondary!)  may  give  rise  to  error.  Thus,  when 
correspondingly  situated  underneath  the  right  costal  arch,  the  lower  free 
border  may  be  easily  mistaken  for  the  border  of  the  liver. 

"'  See  Cases  22,  23,  24  and  25. 

"*  See  page  144. 

"'See  W.  Vassmer,  Deutsche  Zeitschr.  f.  Chiriirgie,  1908,  Vol.  91  (compilation  of 
95  cases). 

""  See  Case  1. 


"ATYPICAL"    MALIGNANT    ABDOMINAL    TUMORS       169 

Remarkable  is  their  smooth,  lamelliform  expansion  in  the  perium- 
bilical situation  as  well  as  in  varying  other  situations. 

Ovaries 
Testicle 

In  conclusion,  we  will  refer  to  one  more  group  of  neoplasms  which 
are  looked  upon  as  rarities,  by  internists  at  least,  namely,  malignant 
growths  of  the  genital  organs, ^"^  especially  the  testicle  and  ovaries.  They 
enter  the  domain  of  medical  diagnosis  when,  like  testicular  neoplasms,  for 
example,  they  have  led  to  retroperitoneal  tumor  formations,  or,  after  the 
manner  of  ovarian  tumors,  develop  far  upward  and  lead  to  ascites.  Those 
examiners  who,  in  every  obscure  case  of  abdominal  neoplasm,  examine  both 
testicles,  so  that  they  may  at  the  same  time  ascertain  proper  descent 
and  on  the  other  hand  also  examine  per  vaginam,  will  run  little  risk  of 
overlooking  these  growths.  It  must,  however,  be  noted  with  stress  that  .a 
primary  neoplasm  of  the  testicles  may  at  times  be  very  small  and  that 
intumescences  of  the  ovaries  may  be  brought  about  by  metastasis  (gas- 
tric cancer!). 

In  diagnostically  obscure  cases  of  apparently  "malignant"  ascites  in 
females  we  must  always  consider  the  possibility  of  ovarian  carcinoma. 
Pseudo-symptoms  of  pregnancy  (pigmentation  of  the  nipples,  etc.),  may 
occasionally,  as  in  Case  2,  lead  one  in  the  right  direction. 

Other  accompanying  symptoms,  especially  in  so  far  as  they  affect  the 
gastro-intestinal  tract,  such  as  slight  manifestations  of  stenosis,  are  rather 
calculated  to  mislead  one.  Retroperitoneal  tumor-masses  occurring  in 
males,  even  though  situated  in  the  epigastrium,  should  always  be  examined 
with  reference  to  their  possible  relations  to  primary  neoplasms  of  the 
testicle. 

"'  See  Cases  1,  2,  3,  4. 


C.  CASE   HISTORIES 


C.  Case  Histories 


111  the  following  accounts  it  will  be  my  endeavor  to  present  short  case 
histories  taken  from  my  own  experience.  Ahiiost  throughout  they  are 
cases  which  I  had  occasion  to  discuss  in  post-graduate  courses,  so  that 
I  can  speak  for  the  correctness  of  the  previous  history  and  the  objective 
findings.  In  the  presentation  of  the  cases  I  am  guided  by  notes  made  |or 
my  personal  use  immediately  after  each  lecture.  Most  of  the  cases  in- 
clude the  notes  of  the  surgeon  or  pathological  anatomist,  and  occasion- 
ally both.  I  have  tried  to  omit  everything  that  was  superfluous  in  order 
to  afford  a  rapid  general  view.  For  this  same  reason  it  seemed  proper  to 
arrange  the  dates  according  to  definite  viewpoints,  so  that  the  material 
may  be  reviewed  easily  in  one  direction  or  another. 

The  arrangement  is  as  follows : 

1.  Ancestry  and  relationship. 

2.  Congenital  peculiarities,  metabolic  diseases,  etc. 

3.  Previous  infectious  diseases.^ 

4.  Previous  history  of  the  digestive  tract. 

5.  Other  previous  history. 

6.  Initial  symptoms  and  further  course. 

7.  Objective  symptomatology. 

8.  Dates  of  events  ^  and  duration  of  disease. 

9.  Findings  at  autopsy  or  laparotomy.^ 

The  greater  portion  of  the  clinical  material  here  to  be  discussed  is 
taken  from  the  II.  Medical  Clinic  in  Vienna  (Hofrat  Professor  Dr.  E.  V. 
Neusser)  ;  the  lesser  portion  from  my  division  at  the  K.K.  Kaiserin  Eliza- 
beth Hospital.  The  autopsies  were  performed  at  the  Pathological  Ana- 
tomical Institute  (Hofrat  Professor  Dr.  A.  Wnch.selbaum)  and  in  the 
prosector's  department  of  K.K.  Kaiserin  Elizabeth  Hospital  (Professor 
Dr.  Fr.  Schlagenhaufer) .  The  operations  were  performed  in  the  clinic 
of  Hofrat  Professor  Dr.  Gussenhauers  and  (after  April  2,  1904- )  his  suc- 
cessor, Hofrat  Professor  Dr.  J .  Hoclienegg. 


M.  D.  C.  =  Infectious  Diseases  of  Childhood. 

^  The  date  of  "Status  presens"  generally  corresponds  to  the  day  on  which  I  had  occa- 
sion to  present  the  case  clinically.    The  date  of  the  "beginning"  has  always  been  inferred 
from  the  previous  history  of  the  patient,  and  naturally  possesses  limited  validity,  just 
like  the  information  as  to  the  "duration"  of  the  disease. 
^  Given  in  epitomized   form  only. 


173 


Carcinoma  of  the  Stomach 


Case  1. — B.  G.,  53  years,  M.^     Conductor. 

ad  2.— Had  two  attacks  of  gout  in  the  spring  of  1898;  swelling  in 
the  joint  of  right  great  toe,  occurring  at  night;  after  a  week  the  same 
joint  in  the  left  side  was  affected. 

ad  4. — Always  had  a  preference  for  acid  foods. 

ad  6. — Anorexia  since  October,  1898 ;  now  and  then  "false"  hun- 
ger. Sensation  of  pressure  after  eating.  Often  attacks  of  dizziness 
upon  arising  in  the  morning.  Sensation  of  "fire"  in  the  stomach  with 
much  thirst. 

ad  7. — Transversely  running  tumor  in  the  epigastrium.  Tongue 
heavily  coated.  Vomiting  extremely  seldom,  only  three  times  of  late. 
Frequent  belching  of  gas,  only  once  having  the  odor  of  rotten  eggs.  Ob- 
stinate constipation.  Emaciation,  losing  20  kg.  Second  aortic  sound 
very  loud,  murmur-like.     Hypertension, 

Urine:  Indican  reaction  {Obermayer)  strongly  positive. 

ad  8. — Beginning:  October,  1898. 

Status  presens:  October  23,  1900. 
Autopsy:   February    18,    1900. 
Duration :  About  2  years,  4  months. 

ad  9. — Autops}^  (Professor  Dr.  A.  Ghon)  :  Infiltrating  gastric  car- 
cinoma, chiefly  in  the  pyloric  portion  of  the  stomach,  with  severe  stenosis 
of  the  pyloris.  Atheromatosis  of  the  aorta  in  high  degree,  especially  in 
the  ascending  portion  and  at  the  arch,  with  dilatation  of  the  ascending 
portion ;  beginning  contraction  of  the  kidneys  as  a  result  of  arterio- 
sclerosis. 

Eplcrisis:  Possibility  of  relationship  between  gout  and  cancer!  The 
dragging  course  (2  years,  4  months)  might  be  dependent  on  the  severe 
atheromatous  disease  in  the  circulatory  system.  The  possibility  of  such 
influence  leading  to  a  poorer  nutrition  of  the  cancerous  tissue  is  held  by 
French  clinicians,  among  others  Bard.^ 

Case  2. — J,  S.,  62  years,  M. 

ad  1, — Father  died  in  advanced  age,  much  emaciated  (Ca..''). 
Mother  died  of  old  age. 

ad  2. — Tubercular  habitus, 
ad  3. — Erysipelas. 

*M  =  Male;  F  =  Female. 
^  Bard.  La  semaine  medicale,  1904,  No.  34. 

174 


CARCINOMA    OF    THE    STOMACH  175 

nd  4. — Since  1879  stomach  suft'ercd;  trequent  bitter  vomiting  early 
in  the  morning  when  stomach  was  empty,  and  eructation  of  gas  during 
many  years;  took  tlie  Karlsbad  cure  in  1887  and  1888  with  good  results. 
For  a  long  time  obstipation,   frequently   sheep-like   stools. 

ad  5. — No  drinker,  moderate  in  eating.  Liking  for  hot  foods,  par- 
ticularly for  very  hot  soup,  no  abuse  of  acid  foods. 

ad  6. — Since  January,  1899,  appetite  very  poor.  Nourished  him- 
self since  Septeml)er,  1899,  with  milk  and  rolls,  lately  only  with  milk.  Se- 
vere burning  in  the  epigastrium.  Relief  after  belching.  Continuous 
thirst. 

ad  7. — Stomach  small,  in  continual  peristaltic  unrest.  Continued 
explosive  belching  without  particular  odor,  with  slightly  sour  taste. 
Tongue  dry.  Systolic  murmur  in  the  epigastrium.  Obstinate  constipa- 
tion. Emaciation  in  highest  degree.  Retromalleolar  edema  and  on  the 
sacrum. 

Vomit:  Fat  globules,  very  small  rod-shapes  (Culture:  bact.  coli),  no 
lactic-acid  bacilli,  no  sarcin«. 

ad  8. — Beginning:  January,  1899. 

Status  presens :  April  26,  1900. 
Autopsy:  May  5,  1900. 
Duration:  About  1  year,  4  months. 

ad  9. — Autopsy  (Docent  Dr.  K.  Landsteiner)  :  Scirrhus  carcinoma 
of  the  stomach  with  infiltration  and  contraction  of  the  whole  stomach- 
wall.  Ulcer  scar  at  the  pylorus.  Carcinoma  of  the  peritoneum  and  the 
reginal  lymph-glands. 

Epicrisis:  A  typical  case  of  diffuse  scirrhus  of  the  stomach!  These 
are  without  doubt  cases  which  are  looked  upon  as  benign,  on  account  of 
lack  of  a  definite  tumor  formation  and  failure  of  metastases,  being  re- 
ferred to  in  the  literature  partly  under  the  name  "linitis  plastica  Br'ni- 
ton:' 

Characteristics  of  this  form  of  stomach  cancer:  Small  stomach,  peri- 
staltic unrest,  continual  regurgitation  (gases),  bact.  coli-growth.^  The 
symptom  of  explosive  eructation  present  could  in  itself  easily  lead  to 
error  (hysteria).  The  strong  gas  formation  might  be  due  to  the  pres- 
ence of  the  bact.  coli  and  the  exclusive  milk  diet  (fermentation).  The 
many  years  of  previous  stomach  complaints  were  probably  due  to  the  ulcer 
at  the  pylorus. 

Case  3. — J.  K.,  65  years,  M.    Laborer. 

ad  1. — Father  and  mother  lived  to  old  age,  brothers  and  sisters  all 
healthy. 

ad  2. — Suffered  since  childhood  from  ichthyosis.  At  the  age  of 
29  he  became  ill  and  had  painful  swelling  in  the  joints  of  both  great  toes 
without  fever,  nightly  occurrence  of  the  affection.  Later  participation 
of  the  ankle  and  knee  joint,  then  the  hip  and  the  joints  of  the  right  arm 

'See  B.  Schmidt.    Wiener  klin.  Wochenschr.,  1901,  No.  2. 


17(5  TUMORS    OF    THE    ABDOMINAL    VISCERA 

and  forearm.  He  was  confined  in  bed  one-half  year  and  suffered  from 
nocturnal  exacerbations  of  pain.  In  Karlsbad,  arthritis  urica  was  diag- 
nosed. Since  that  time,  in  spring  and  autumn,  frequent  slight  joint  pains. 
At  the  age  of  46  he  suffered  another  severe  attack.  Was  in  the  hospital 
nine  weeks.  Nodules,  which  disappeared,  formed  in  the  forearm.  At 
that  time  was  operated  on  for  hallux- valgus. 

ad  3. — At  the  age  of  31,  fever  attacks  every  second  day  with 
chill,  feeling  of  heat  and  sweat,  received  "bitter"  powders.  Perhaps 
malaria. 

ad   -i. — Always  had  very  good  appetite. 

ad  5. — Hard  drinker. 

ad  6. — In  the  night  of  April  7,  1900,  sudden  nausea  and  vomiting. 
Appetite  good,  has  eaten  meats  until  lately,  although  at  night  he  always 
vomited  copiously.  Complains  of  burning  pains  in  stomach,  particularly 
after  eating,  also  sour  and  bitter  eructations. 

ad  7. — Tongue  slightly  coated,  teeth  very  defective,  ^'isible  gas- 
tric peristalsis  accompanied  by  hiccough.  Considerable  vomiting,  par- 
ticularly in  the  middle  of  the  night.  By  assuming  the  right  lateral  posi- 
tion severe  eructation  and  rather  severe  vomiting.  Constipation.  Tym- 
panitic sounds  in  the  region  of  the  liver.  Pulse  44,  hypo-tension.  No 
edema. 

Stomach  contents:  Lactic-acid  bacilli  most  profuse,  no  hydrochloric 
acid. 

Blood:  Ugh.,  70%;  erythrocytes,  4,500,000;  leucocytes,  10,000. 

ad   8.— Beginning:  April,  1900. 

Status  presens :  June  12,  1900. 
Epicrisis:  Remarkable  is  the  presence  of  a  constitutional  defect  as 
expressed  by  ichthyosis  and  uric  acid  diathesis.'^  Hallux-valgus  appears 
to  me  in  many  cases  to  be  a  sign  of  latent  uric-acid  diathesis.  The  case 
deserves  interest  from  the  standpoint  of  the  connection  between  skin  and 
metabolism.  Tympanites,  in  place  of  the  liver  dulness,  is  a  frequent  find- 
ing in  cases  of  pyloric  stenosis.  When  the  pyloric  orifice  is  stenosed,  the 
severity  of  the  regurgitation  often  increases,  by  assuming  the  right  lateral 
position  (eructation,  vomiting). 

Case  4. — F.  W.,  55  years,  M.    Laborer. 

ad  2. — Was  alwa^^s  healthy. 

ad  5. — At  the  close  of  1896,  after  lifting  a  heavy  load,  pains  in 
the  region  of  the  umbilicus  of  three  weeks'  duration..  Abdomen  distended. 
Loss  of  appetite  and  frontal  headache ;  otherwise  there  occurred  no  at- 
tacks of  nausea,  no  vomiting,  bowels  were  regular.  No  alcoholism ;  led 
regular  life. 

ad  6. — In  January,  1899,  loss  of  appetite  and  drawing  pains  be- 
gan in  the  lower  abdomen,  which  occurred  twice  daily,  now  and  then  at 
night.     Since  that  time  often  no  stool  for  from  six  to  seven  da^^s.     Feel- 

'  Compare  Case  1. 


CARCINOMA    OF    THE    STOMACH  177 

ing  of  pressure  in  the   stomach   after  eating,   fi'equently   odorless   eruc- 
tations of  gases  and  heartburn.     Distaste  for  boiled  beef. 

ad   7. — Tongue  only  slightly  coated.     Teeth  very  defective.     Tu- 
mor  of  the  pylorus   palpable.      Considerable   "coffee-ground"   vomiting, 
with  abundant  lactic-acid  bacilli  and  sarcina\     No  edema. 
Feces:  Abundant  cercomonas  intestinales. 
ad  8. — Beginning:  January,  1899. 

Status  presens:  May  16,  1900. 
Duration :  About  1  year,  4  months. 
Epicrisis:  The  abdominal  complaints  which  occurred  in  1896  (after 
the  lifting  of  a  heav}^  load)  could  possibly  have  been  the  expression  of  an 
ulcer  of  the  stomach. 

We  are  justified  in  speaking  here  of  a  "gastric"  obstipation.  The  ob- 
stipation is  indeed  frequently  an  early  symptom  of  gastric  cancer.  The 
"monadenfauna"  ^  is  here  an  intestinal  one,  as  it  sometimes  is  met  with 
in  cases  of  achylia  gastrica.  This  finding  in  the  feces  brings  to  mind  the 
idea  of  an  insufficient  secretion  of  hydrochloric  acid.  There  never  oc- 
curred a  gastric  monadenfauna  in  pyloric  carcinoma,  although  not  sel- 
dom in  carcinoma  of  the  cardia. 

Case  5. — G.  J.,  43  years,  M.    A  mother-of-pearl  worker. 

ad  3. — At  the  age  of  2  had  smallpox  (the  smallpox  scars  visible). 

ad  4. — Never  had  stomach  complaints. 

ad  5. — Was  always  healthy. 

ad  6. — In  the  fall  of  1899  vomited  six  or  seven  times.  In  Febru- 
ary severe  vomiting  after  eating  "goulash,"  from  then  on  daily.  No 
pains.  Was  very  much  weakened  by  a  Karlsbad  cure.  Loss  of  weight 
of  about  40  kg!      Acid  eructations,  burning  in  the  throat. 

ad  7. — Tongue  thickly  coated,  teeth  defective.  Distinct  gastric 
peristalsis  with  accompanying  hiccough.  Doughy  consistence  of  the  skin, 
so  that  after  pressure  of  the  finger  upon  the  abdomen  and  also  over  the 
sternum  there  remains  a  small  depression.  No  edema  over  the  tibia,  no 
retromalleolar  edema. 

Stomach  contents:  "Coffee-grounds,"  no  free  HCl,  abundant  lactic- 
acid  bacilli. 

ad  8.— Beginning:  Fall,  1899. 

Status  presens:   July  18,  1900. 
Autopsy :  June  22,  1900. 
Duration:  About  1  year,  10  months. 

ad  9. — Autopsy :  Polypoid  carcinoma  of  the  pylorus,  constricting 
in  high  degree.  Small  metastases  in  the  regional  serosa,  numerous  metas- 
tases in  the  liver  as  large  as  hazel  nuts. 

Epicrisis:  In  the  diagnosis  of  stomach  diseases  one  has  always  to 
consider  the  individuality  of  the  patient.  With  "stomach  athletes"  who 
always  had  enjoyed  the  best  digestion,  nearly  every  severe  gastric  dis- 

*  Compare,  among  others,  A.  Cohnheim,  Deutsche  med.  Wochenschr.,  1908,  No.  .% 
and  U.  Gwastalla,  Wiener  klin.  Wochenschrift,  1909,  No.  45. 


178  TUMORS    OF    THE    ABDOMINAL    VISCERA 

turbance,  if  it  is  not  cured  in  a  very  short  time,  must  awaken  the  sus- 
picion of  malignancy ;  also  the  bad  result  of  a  Karlsbad  cure  should  cause 
us  always  in  analogous  cases  to  think  of  carcinoma. 

The  pitting  of  the  skin  over  the  abdomen  and  over  the  sternum  is  here 
not  caused  by  edema  but  by  a  peculiar  lo.s-s  of  elasticity  of  the  skin  which 
one  not  seldom  finds  in  constricting  stomach  carcinoma  with  copious  loss 
of  fluid  as  result  of  continuous  vomiting. 

Case  6.— N.  N.,  78  years,  F. 

ad  5. — Twelve  children. 

ad  6. — In  October,  1898,  vomiting  and  odorless  eructations  began, 
revulsion  against  meat.  Since  the  beginning  of  October,  1899,  the  abdo- 
men became  gradually  larger. 

ad  7. — In  the  epigastrium  one  feels  a  transversely  situated,  very 
hard  roll,  but  which  in  the  next  moment  feels  soft;  at  the  same  time  loud 
gurgling.  Ceaseless  vomiting.  Stomach  contracted  and  in  continuous 
peristaltic  unrest.  Severe  ascites,  which  toward  the  end  disappears  en- 
tirely. Water  can  be  taken  only  by  the  teaspoonful,  but  these  small 
quantities  come  back  again  immediately. 

Obstipation  in  the  last  months ;  feces  lead  pencil-like.  Four  centi- 
metres above  the  anus  a  uniformly  circular  constricted  point,  over  which 
the  mucous  membrane  is  drawn  unchanged  (stenosis  from  without!). 
Sudden  occurring  painful  swelling  of  the  left  leg.  Left-sided,  slightly 
sero-sanguineous  pleural  effusion. 

Blood:  4,500,000  erythrocytes ;  26,000  leucocytes. 

In  the  last  days  almost  complete  retrogression  of  the  ascites,  of  the 
left  pleural  effusion  and  of  the  edema  in  the  left  lower  extremity.     High- 
est temperature,  37.3°   C.     In  the  terminal  coma  aspiration  movements 
(expression  of  an  enormous  feeling  of  thirst!), 
ad  8. — Beginning:  October,  1898. 

Status  presens:  October  30,  1899. 
Autopsy:  November  15,  1899. 
Duration :  About  a  year, 
ad  9. — Autopsy  (Professor  Dr.  0.  Stoerk)  :  Scirrhus  carcinoma  of 
the  stomach,  with  carcinomatosis  of  the  peritoneum. 

Epicrisis :  An  analogue  to  Case  2 !  No  circumscribed  tumor  forma- 
tion, but  a  diffuse,  uniform  infiltration  of  the  whole  stomach-wall  with 
enormous  constriction  of  the  lumen. 

Continuous  peristalsis  with  resulting  high-grade  changes  in  the  con- 
sistence of  the  palpable  stomach-canal  (stone  hard  to  soft!),  and  abso- 
lute intolerance  of  even  the  smallest  amount  of  fluid. 

The  patient  can  take  to  herself  from  without  no  fluid,  since  even  the 
smallest  amount  is  immediately  vomited.  She  drinks,  therefore,  toward 
the  end  from  her  owm  internal  fluid  depots  (ascites,  pleural  exudate, 
edema  of  the  left  leg),  and  there  occurs  a  mummification  of  the  former 
dropsical  patient.  Even  in  the  coma,  movements  of  aspiration,  as  if  she 
would  drink. 


CARCINOMA    OF    THE    STOMACH  179 

Case  7. — Sch.  U.,  65  years,  F.     Laboring  woman. 

ad  6. — 111  since  the  beginning  of  September,  1899.  There  began 
pains  in  the  stomach,  particularly  after  eating.  Bitter  and  sour  eructa- 
tions, vomiting.  From  beginning,  severe  constipation.  Severe  tender- 
ness to  pressure  underneath  the  left  costal  arch  and  in  the  left  axillary 
line  over  the  lower  intercostal  spaces.  Inguinal  glands  on  left  side  painful, 
ad  7. — Tongue  coated,  the  right  side  more  than  the  left.  Meteor- 
ism  of  moderate  degree;  tumor  not  palpable.  Lower  abdominal  region 
very  tense.     In  the  lower  left  quadrant,  bowel  peristalsis  visible. 

A  gland  in  the  left  groin  swollen,  painful,  later  becomes  smaller  and 
less  painful.     Left-sided  pleural  effusion  after  friction  in  the  left  axilla. 
Aspiration:  Cloudy  effusion,  with  very  numerous  leucocytes.     Severe 
retromalleolar  edema.     Second  aortic  sound  ringing.     Highest  tempera- 
ture in  the  last  days,  39.6°  C. 

ad  8. — Beginning:  First  part  of  September,  1899. 
Status  presens:  November  4,  1899. 
Autopsy:  November  13,  1899. 
Duration:  Two  months  (.''). 
ad  9. — Autopsy   (Professor  Dr.  H.  Albrecht)  :  Carcinoma  of  the 
stomach  of  both  the  small  and  greater  curvatures,  without  stenosis  of 
the   pylorus   with   secondary   carcinomatosis    of   the   peritoneum.      Sub- 
phrenic abscess,  about  the  size  of  an  apple,  between  the  spleen,  stomach 
and  diaphragm;  some  pus  in  Douglas  cul-de-sac.     Fibrinous  suppurative 
pericarditis  and  left-sided  pleuritis.     Multiple  contraction  of  the  bowel 
through  the  carcinomatous   infiltration.      Ascending  aorta  very  athero- 
matous and  dilated.     Chronic  tuberculosis  of  lymph-glands  of  the  neck. 
Epicrisis:  Carcinoma  of  the  stomach  as  the  cause  of  left-sided  sub- 
phrenic abscess  and  of  left-sided  suppurative  pleuritis  and  fibrinous  peri- 
carditis ;  in  the  beginning  as  the  result  of  cachexia,  no  essential  tempera- 
ture rise. 

Case  8. — N.  N.,  40  years,  M.     Machinist. 

ad  6. — In  the  beginning  of  November,  1897,  stomach  trouble  began 
suddenly ;  eructations,  very  sour  vomiting,  one-half  hour  after  taking 
food.  July,  1898,  a  palpable  tumor  in  the  epigastrium.  Winter  of 
1898-99,  the  stomach  difficulties  disappeared  entirely,  he  could  eat  every- 
thing, except  large  portions.  Since  April,  1899,  severe  edema  of  the 
lower  extremities.  Bowels  always  regular.  Since  June,  1899,  strong  feel- 
ing of  thirst  as  result  of  a  feeling  of  internal  heat.  Moderate  polyuria. 
Appetite  and  stool  with  essential  disturbances.  By  assuming  a  left  lat- 
eral position,  he  experiences  the  feeling  as  if  a  heavy  mass  sank  towai-d 
the  left.  Feeling  of  hot  and  cold  along  the  spine.  Increase  of  the  pains 
in  the  back  by  pressure  upon  the  tumor. 

ad  7. — A  tumor  about  the  size  of  the  palm  of  the  hand,  in  the 
centre  of  which  lies  the  navel ;  the  tumor  is  hard,  uneven,  pulsates  strong. 
Over  the  same  a  systolic  murmur  is  audible ;  slight  respirator}'  mobility, 
also,  by   diaphragmatic   breathing.      The   tongue   not   coated.      Bronze- 


180  TUMORS    OF    THE    ABDOMINAL    VISCERA 

like  pigmentation  in  the  face,  on  the  forehead,  neck  and  extensor  surfaces 
of  the  upper  extremities.  Pigment  spots  on  the  soft  palate  and  on  the 
mucous  membrane  of  both  cheeks. 

Blood:  Hemoglobin,  30%  ;  2,800,000  erythrocytes:  18,000  leucocytes, 
among  which  were  8%  cosinophiles. 

Urine:  Slight  polyuria,  traces  of  sugar. 

Stomach  contents:  For  the  first  time,  toward  the  end,  vomiting,  and 
about  two  litres  of  blood,  lactic-acid  bacilli  very  profuse, 
ad  8. — Beginning:  November,  1897. 

Status  prcsens:  November  9,  1899. 
Autopsy:  November,  1899. 
Duration :  Two  years, 
ad  9. — Autopsy :    High-grade    ulcerative    soft,    carcinoma    corre- 
sponding to  the  pylorus,  without  stenosis.     Tumor  grown  to  the  abdomi- 
nal wall,  the  left  lobe  of  the  liver  and  attacking  the  pancreas,  the  head  of 
which  is  infiltrated. 

Spleen  enlarged.     Thrombosis  of  tiie  right  crural  vein. 

Ejncrisis:  It  is  not  a  seldom  occurrence  that  in  very  large  stomach 
tumors,  as  we  have  here,  stomach  complaints  are  absent  for  a  long  time, 
almost  entirely.  Disturbances  on  the  part  of  the  stomach  exist  in  the 
above  reported  case,  only  in  the  beginning  and  toward  the  end.  One  can 
truly  say,  the  fact  somewhat  underlined:  the  greater  the  stomach  tumor, 
the  less  the  stomach  complains !  The  explanation  for  this  seems  to  me 
to  be  in  the  absence  of  a  stenosis. 

The  large  soft  carcinomas,  as  was  here  the  case,  ulcerate  very  se- 
verely, so  that  it  does  not  come  to  a  lasting  stenosis.  The  pyloric  out- 
let becoming  free,  the  stomach  symptoms  existing  in  the  beginning  dis- 
appear again  completely ;  so  also  here.  By  an  anatomical  progressive 
process  a  disappearance  of  the  s^'mptoms  can  functionally  take  place. 

The  constipation  in  carcinoma  of  the  stomach  could  result  perhaps 
partly  from  a  pyloric  stenosis  and  gastric  stagnation;  it  was  perma- 
nently absent.  Of  interest  is  the  peculiar  skin  and  nmcous  membrane  pig- 
mentation, combined  with  eosinophilia  of  the  blood;  pigment  anomalies, 
which  are  found  in  affections  accompanied  by  severe  cachexia  (stomach 
cancer,  tuberculosis,  and  cancer  of  the  pancreas,  etc.),  of  course  not  fre- 
quently (v.  Recklinhausen's  hemochromatosis).^ 

Case  9.— J.  S.,  36  years,  M.    Tailor. 

ad   1. — One  sister  died  of  cancer  of  the  stomach  {?). 

ad  4. — Beginning  of  gastric  illness,  five  years  ago ;  the  patient  vom- 
ited almost  every  week  once  after  eating,  without  experiencing  pain. 
Frequently  the  feeling  of  ("setting  up")  in  the  epigastrium  (as  if  a 
worm  were  in  the  abdomen).     The  appetite  always  good. 

ad  6. — Since  two  years  ago  the  vomiting  became  more  frequent. 
The  patient  became  pale  and  lost  weight.     For  the  past  six  months  almost 

"Compare  W.  Mar/er.  Skin  Melanosis  in  Diseases  of  the  Pancreas.  Zentralbl.  f. 
Grenzgeb.  d.  Chir.,  IV,  page  2-25. 


CARCINOMA    OF    THE    STOMACH  181 

every  day  stomach  craiups,  radiating  into  the  left  half  of  the  thorax  and 
"up  as  far  as  the  head." 

ad  7. — The  tongue  thickly  coated.  A  tunior-niass  palpable  in  the 
epigastrium,  over  which  friction-sounds  were  audible.  Second  aortic  tone 
ringing, 

ad   8. — Beginning:  December,  1897. 

Status  presens:  December  2,  1899. 
Autopsy:  February  10,  1900. 
Duration:  2  years,  2  months, 
ad  9. — Autopsy    (Professor  Dr.  H.   Alhrecht)  :  Ulcerating  carci- 
noma of  the  fundus  and  of  the  cardiac  end  of  the  stomach,  with  metastases 
in  the  regional  lymph- glands  and  in  the  head  of  the  pancreas.     Jejunos- 
tomy,  February  3,  1900.     Atheroma  of  the  abdominal  aorta  with  numer- 
ous thrombi  in  the  walls;  from  here  emboli  of  the  right  iliac  artery  and 
of  the  left  femoral  artery. 

Epicrisis:  The  severe  atheroma  of  the  abdominal  aorta  in  a  36-year- 
old  patient  deserves  to  be  reported  as  remarkable. 

This  affection  was  the  terminal  cause  of  death,  there  being  sudden 
manifestations  of  a  blood-vessel  closure  of  the  large  arteries  of  the  lower 
extremities  (the  patient  was  in  the  clinic  of  the  Hofrat  Professor  E.  Al- 
bert, after  laparotomy.  (Embolism  of  the  right  iliac  artery  and  of  the 
left  femoral  artery  !)  The  severe  atheromatous  disease  of  the  abdominal 
aorta  is  etiologically  unexplained. 

Case  10. — F.  J.,  57  years,  M.     Carpenter. 

ad   1. — Mother  died  from  a  pulmonary  disease. 

ad  ^. — Appetite  was  always  good. 

ad  5. — Suffered  much  since  early  childhood  from  cough,  particu- 
larly in  bad  weather.  During  the  past  year  "pulmonary  catarrh,"  with 
night-sweats ;  remained  in  the  house  about  five  months. 

ad  6. — The  patient  noticed  in  1899  a  tumor  between  the  navel  and 
the  lower  end  of  the  breast-bone;  since  then  has  frequently  the  feeling 
that  in  swallowing  something  sticks,  this  being  accompanied  by  nausea 
and  pressure  in  the  stomach.  After  several  minutes  the  food  passes  down- 
ward. Appetite  good,  though  alv/ays  pressure  and  feeling  of  tension  in 
the  stomach  after  nourishment. 

ad  7.- — Tongue  coated,  mucous  membrane  somewhat  atrophic  in 
spots.  Swallowing  of  fluid  difficult,  sensation  of  sticking;  finely  masti- 
cated meat  is  swallowed  better.  No  vomiting.  Blowing  systolic  murmur 
in  the  region  of  a  large  liver  metastasis.  Frequent  thoracic  breathing, 
with  soft  respiratory  murmurs.     Severe  retromallcolar  edema. 

ad  8. — Beginning:  1899. 

Status  presens :  February  13,  1900. 
Autopsy:  March  13,  1900. 

ad  9. — Autopsy  (Professor  Dr.  O.  Stoerk)  :  Scirrhus  and  infil- 
trating carcinoma  originating  in  the  smaller  curvature  near  the  cardia  and 
infiltrating  a  large  part  of  the  stomach  with  extensive  metastases  in  the 
liver;  many  small  metastases  in  the  left  pleura. 


182  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Epicrisis:  As  a  result  of  stenosis  of  the  cardia,  deglutition  difficulties 
became  very  prominent.  Remarkable  is  a  loud  systolic  murmur  in  the 
region  of  the  liver  metastases. 

Case  11. — J.  M.,  50  years,  M.     Cabinet  maker. 

ad  3.- — At  the  age  of  34  had  a  left-sided  pneumonia,  which  lasted 
three  weeks,  otherwise  always  healthy. 

ad  6. — Beginning  of  August,  1899,  pain  in  the  epigastrium  be- 
gan, radiating  from  both  sides  toward  the  middle,  "as  if  a  crab  had 
pinched  with  both  claws."  Burning  pains  in  the  right  upper  quadrant  of 
the  abdomen  and  feeling  of  heat  in  the  back,  one-half  hour  after  eating; 
at  the  same  time,  to  the  right  above  the  umbilicus,  a  sausage-like  projec- 
tion. Eructation  of  bitter  and  sour  food.  Such  attacks  daily  in  the 
beginning,  later  only  two  or  three  times  in  the  week. 

November,  1899,  the  attacks  of  pain  became  less  frequent,  pains  in 
the  back  continuous. 

October,  1899,  fourteen  days'  irregular  fever  and  emaciation.  Appe- 
tite good.  Increase  of  the  symptoms  in  the  right  lateral  position.  Vom- 
iting after  potatoes,  bread,  coffee,  sour  and  hot  edibles. 

February,  1900:  Pains  only  after  inappropriate  nourishment,  and 
when  in  the  right  lateral  position. 

April,  1900:  Back  pains  disappeared.  Appetite  good;  predilection 
for  meat.     Antipathy  against  acid  foods. 

May,  1900:  Pains  in  the  abdomen,  particularly  toward  midnight.  Ap- 
petite very  good,  also  appetite  for  meat.  No  s3Mnptoms  after  taking 
nourishment.  Spinal  column  very  sensitive  to  pressure,  corresponding 
to  third  and  twelfth  dorsal  vertebra?. 

July,  1900:  No  pain  in  the  epigastrium,  only  pains  in  the  back.  Ap- 
petite poorer.  Severe  sensitiveness  to  pressure  of  the  spinal  column  be- 
tween the  shoulder-blades. 

ad  7. — February,  1900:  Tongue  very  heavily  coated,  teeth  very 
defective.  Tumor  not  palpable  in  the  epigastrium,  pain  upon  pressure 
below  the  xiphoid  process.  Indican  reaction  (Obermayer)  strongly  posi- 
tive. No  edema.  On  the  mucous  membrane  of  the  cheeks  and  hard  palate 
on  both  sides  brownish  pigment  spots. 

April,  1900:  Indistinct  resistance  in  the  liver  region.  Systolic  mur- 
mur in  the  epigastrium  most  distinctly  audible,  particularly  at  the  end 
of  expiration.  The  patient  feels  a  protuberance  ( Aufstellung)  in  the 
epigastrium,  accompanied  by  gurgling.  Now  and  then  slight  intestinal 
peristalsis  above  Poupart's  ligament.     Severe  retromalleolar  edema. 

May,  1900:  The  patient  himself  feels  individual  tumors  in  the  epi- 
gastrium, and  remarks  that  they  change  their  position.  Underneath  the 
xiphoid  process  is  a  tumor,  which  in  the  left  lateral  position  can  be  dis- 
placed down  and  to  the  left.  jMetastases  palpable  on  the  surface  of  the 
liver.  Severe  anemia,  25%  Hemoglobin.  No  edema, 
ad  8. — Beginning:  August,  1899. 

Last  status  presens:  July,  1900. 
Duration :  About  one  year. 


CARCINOMA    OF    THE    STOMACH  183 

Epicrisis:  The  ck'inent  of  pjiin  appears  strongh'  in  the  foreground 
in  the  above  observation  and  lends  the  case  an  ulcer-like  symptom  com- 
plexion. Doubtlessly  the  process  began  as  cancer  of  the  pylorus.  The 
appetite  remained  good  for  a  long  time  and  meat  was  borne  well.  I 
have  observed  fre()ueiitly  in  stenosis  of  the  pylorus^'*  slight  intestinal 
peristalsis    (accompanying  movements   of  the   intestines.''). 

The  systolic  "epigastric  murmur"  occurs  in  this  case  before  the  pal- 
pability of  the  tumor. 

Case  12.— D.  F.,  42  years,  M.     Carpenter. 

ad   1. — No  hereditary  diseases. 

ad  2. — Phthisical  habitus. 

ad   5. — Was  always  healthy  until  January,  1900. 

ad  6. — .January,  1900,  pains  in  the  whole  abdomen,  soon  there- 
after stomach  symptoms,  vomiting,  emaciation. 

ad  7. — Tongue  moist,  somewhat  coated.  Ascites  of  moderate  de- 
gree, milk-like  cloudiness  ("chyliform"). 

ad  8. — Beginning:  January,  1900. 

Status  presens :  November,  1900. 
Autopsy:  December  13,  1900. 

ad  9. — Autopsy  (Hofrat  Professor  Dr.  yi.  Weichselbaum)  :  Dif- 
fuse scirrhus  of  the  whole  stomach,  with  strongly  contracting  metastases 
in  the  peritoneum,  particularly  in  the  small  and  large  curvatures  of  the 
stomach,  growing  on  to  the  left  musculus  quadratus  lumboinim  and  psoas 
with  stenosis  of  the  pyloric  orifice.  Hemorrhagic  ascites,  bilateral  hydro- 
thorax.  Individual  calcified  tubercles  in  the  right  upper  lobe.  Hyper- 
trophy of  the  middle  lobe  of  the  prostate  with  hypertrophy  of  the  bladder 
and  cystitis.  Numerous  metastases  in  the  spinal  column,  in  the  ribs,  in 
the  thigh. 

Epicrisis:  Similar  cases,  with  ascites  and  pleural  exudate  in  patients 
of  phthisical  habitus,  can  easily  be  mistaken  for  tuberculosis  of  the  serous 
membranes.  In  the  differential  diagnosis  observe  particularly:  "milky" 
character  of  the  effusion,  afebrile  course,  the  absence  of  the  diazo 
reaction. 

Case  13.— A.  L.,  34  years,  M.    Office  clerk. 

ad   1. — Father  died  in  old  age. 

ad  2. — Phthisical  habitus. 

ad  4. — Always  had  a  good  appetite.  Preference  for  spic}'  and 
sour  foods. 

ad  5. — "Was  always  healthy." 

ad  6. — In  the  beginning  of  1899  occurrence  of  burning  pains  in 
the  region  of  the  gall-bladder,  radiating  into  the  epigastrium,  back  and 
lateral  portions  of  the  thorax,  also  into  the  left  shoulder.     In  the  begin- 

^^  Compare  Anschiitz,  Grenzgebiete  fiir  Chirurgie  und  interne  Medizin,  1907,  III. 
Suppl.,  page  516. 


1H4<  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ning  eructations,  which  afforded  relief,  later  sour  eructation.  In  the  be- 
ginning amelioration  of  the  complaints  through  ingestion  of  warm  soup, 
warm  milk,  cataplasms ;  later  all  this  without  avail.  High  fever  and 
diarrhea  for  some  days.  Intolerance  for  sour  foods.  Impossible  to  lie 
on  right  side  during  attack  of  pain ;  when  free  from  pain  position  made 
no  difference. 

October,  1899  (daily  lavage  of  the  stomach  during  the  evening)^ 
even  on  a  mixed  diet  no  gastric  complaints. 

November,  1899,  feeling  "as  if  there  were  no  room  in  the  stomach." 
Continuous  pains  in  the  epigastrium,  radiating  into  the  back.  Anoi'exia. 
Pains  in  the  back  increasing  and  diminishing  with  the  pains  anteriorly  in 
the  epigastrium. 

ad  7. — September  6,  1900:  Tongue  moist,  slightly  coated.  Abdo- 
men not  tender  to  pressure;  indistinct  transverse  swelling  in  the  epigas- 
trium. The  patient  himself  has  on  occasion  of  an  attack  of  pain  felt  a 
transverse  cord.  The  attacks  of  pain  are  accompanied  by  gastric  peri- 
stalsis. Pressure  over  the  pylorus  elicits  prolonged  borborygmi.  Pale 
yellow  coloration.  Skin  dry,  peeling  off".  HCl  positive  in  gastric  con- 
tents withdrawn  from  fasting  stomach. 

October,  1900:  Cylindrical  tumor,  having  the  diameter  of  the  index 
finger,  about  4  cm  below  the  xiphoid  process.  Nominal  tenderness  to 
pressure.  Soft,  blowing  systolic  murmur  in  the  epigastrium.  Edema. 
HCl  positive  on  fasting  stomach,  sarcina?.     Patient  has  no  complaints. 

November  12,  1900:  Tumor  more  distinct,  sensitive  to  pressure.  Bow- 
els regular.     Retromalleolar  edema. 

ad  8. — Beginning:  Early  part  of  1899. 

Status  presens:  September  6,  1900.     October  4-,  1900.     No- 
vember 12,  1900. 
Autopsy:  November  14,  1900. 
Duration:  About  1  year,  10  months, 
ad  9. — Autopsy:  Carcinoma  of  the  pyloric  region  of  the  stomach. 

Epicrisis:  In  this  case  also  the  element  of  pain  comes  into  the  fore- 
ground in  the  beginning  and  during  the  further  course  of  the  disease. 
Here  we  have  those  wide  radiations  peculiar  to  the  "colic  of  pyloric 
stenosis"  described  by  me.^^  The  long  persistence  of  HCl  secretion  is  at 
any  rate  a  factor  promoting  pain.  The  patient's  own  observation  that  a 
transverse  cord  could  be  felt  in  the  epigastrium  (pyloric  spasm  before  the 
stenosis)  is  worthy  of  note. 

Case  14.— H.  T.,  52  years,  F. 

ad  1.- — Father  died  probably  of  cancer  at  53,  one  sister  died  of 
tuberculosis. 

ad  2. — Meagre  stature. 

ad  3. — Passed  through  several  diseases  of  childhood. 

ad   4. — Always  had  a  good  stomach,  could  tolerate  everything  well. 

"  R.  Schmidt.  Die  Schmerzphanomene  bei  inneren  Krankheiten,  etc.  Second  edi- 
tion, 1910. 


CARCINOMA    OF    THE    STOMACH  185 

ad  5. — Always  healthy;  menstruation  absent  for  one  year. 
ad  6. — Emaciation  since  October,  1900.     Poor  appetite  since  De- 
cember, 1900.     Hitlierto  no  vomiting.     "Water  often   runs  together   in 
mouth."     Sensation  of  pressure  in  stomach. 

ad  7. — Mucosa  of  the  tongue  smooth  in  the  middle  portions,  shiny, 
atrophic.  Hard  tumor  at  the  pylorus.  Light  peristalsis  of  intestinal 
loops  above  Poupart's  ligament.     Pale  yellow  color  of  face.     No  edema. 

Stomach  contents:  No  HCl,  abundance  of  lactic-acid  bacilli  and  yeast- 
cells. 

ad  8. — Beginning:  October,  1900. 

Status  presens:  April  23,  1901. 
Duration  :  About  7  months. 
Epicrisis:  In  regard  to  "stomachal"  intestinal  peristalsis,  we  refer  to 
Case  11. 

Case  15.— S.  J.,  46  years,  F. 

ad  2. — First  menstruation  at  17  years  of  age. 

ad  3. — Measles  at  4;  pulmonary  disease  at  34,  received  16  of 
Koch's  injections,  remained  in  bed  3  months. 

ad  4. — Stomach  complaints  for  past  10  years. 

ad  5. — In  May,  1899,  fell  from  stairs,  striking  region  of  the  stom- 
ach. In  1899  was  treated  for  articular  rheumatism.  Has  not  eaten 
meat  for  one  year. 

ad  6. — Last  menstruation  March,  1900.  In  lower  abdominal  region 
frequent  sensation  of  contraction.  Dorsal  vertebra^  very  tender  on  per- 
cussion, especially  at  the  height  of  the  angle  of  the  scapula.  For- 
merly for  a  long  time  pains  in  back  in  dorsal  position,  now  only  when 
sitting. 

ad  7. — Sensitive  tumor  in  the  epigastrium.  Liver  metastases.  Se- 
vere edema  of  the  lower  extremities  and  over  the  sacrum. 

ad  8. — Beginning:  March,  1900. 

Status  presens:  September  21,  1900. 
Autopsy:  October  22,  1900. 
Duration  :  7  months  (  ?). 

ad  9. — Autopsy  (Professoi  Dr.  H.  Glion):  Soft  carcinoma  in  the 
wall  of  the  stomach  near  the  lesser  curvature,  superimposed  on  a  round 
ulcer,  invading  the  pancreas,  which  had  grown  to  the  posterior  wall  of 
the  stomach.     Multiple  metastases  in  the  liver. 

Epicrisis:  The  localized  sensitiveness  on  percussing  the  vertebral  col- 
umn at  about  the  level  of  the  angle  of  the  scapula  is  worthy  of  note ;  the 
phthisical  antecedents  could  easily  awaken  the  suspicion  of  a  beginning 
spondylitis.  Undoubtedly,  however,  we  were  dealing  with  a  gastric  reflex 
symptom,  which  often  appears  also  in  gastric  ulcer. 

Cessation  of  the  menstrual  periods  might  count  among  the  early 
symptoms. 

About  one  year  previous  to  the  beginning  of  the  cancerous  disease  a 
trauma  to  the  epigastrium. 


186  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  16. — J.  K.,  57  years,  M.     Cabinet  maker. 

ad  2. — Ton^e  indented. 

ad  3. — No  I.  D.  C. ;  at  13  was  unconscious  for  4  weeks  (Ty.  2). 

ad  4. — Appetite  always  good,  bowels  regular;  never  had  pains  in 
the  stomach.  Preference  for  highly  salted  and  spiced  foods;  was  com- 
pelled always  to  eat  rapidly. 

ad  5. — No  alcohol ;  no  nicotine. 

ad  6. — In  May,  1900,  without  preceding  indigestion,  whilst  at  work 
was  taken  with  cutting,  burning  pains  in  the  region  of  the  stomach,  dis- 
tention of  that  organ;  the  pains  lasted  one  to  two  hours,  limited  to  the 
epigastrium.  These  pains  subsequently  occurred  daily.  During  the  at- 
tack the  patient  found  relief  by  pressing  wnth  his  hand  over  the  region  of 
the  stomach.  Later  on  he  noticed  an  erectile  feeling  and  hardening  in 
the  pit  of  the  stomach.  Eructation  brings  relief,  likewise  sometimes  the 
ingestion  of  food.  Constipated  since  May,  1900.  Appetite  good,  but 
distress  immediately  after  meals.  No  vomiting.  Pains  occur  more  easily 
when  stomach  is  empty;  daily  odorless  eructation  and  heartburn.  Posi- 
tion exerts  no  influence.  Very  frequent  nocturnal  pains  in  the  epigas- 
trium, together  with  hardening  of  the  same. 

ad  7. — Teeth  defective.  Tumor  underneath  the  left  costal  arch. 
Hoarseness  since  appearance  of  stomach  complaints,  cannot  speak  loud 
any  more.  Frequent  hiccough.  In  the  morning  on  arising  nausea  and 
vomiting.  Since  June,  1900,  often  swelling  of  the  feet  during  the  day, 
regress  at  night. 

ad  8. — Beginning:  May,  1900. 

Status  presens:  October  15,  1900. 
Autopsy:  March  26,  1901. 
Duration:  About  11  months. 

ad  9. — Autopsy:  (Professor  Dr.  H.  Ghon)  :  Disintegrating  papil- 
lary carcinoma  of  the  pyloric  portion  of  the  stomach,  with  stenosis  of  the 
pylorus  and  dilatation  of  the  stomach.  Tuberculosis  in  the  left  pul- 
monary apex,  with  small  hazelnut  size  cavity. 

Epicrisis:  "Colics  of  pyloric  stenosis"  precede  demise  by  about  eleven 
months.  A  rapidly  occurring  pyloric  stenosis  is,  almost  always,  of  ma- 
lignant origin.  Benign  ulcerous  processes  require  a  long  time  to  produce 
stenosis  by  way  of  cicatricial  contraction. 

Case  17.— B.  A.,  52  years,  M. 

ad  1. — No  cancerous  disease  in  the  family. 

ad  2. — In  1884,  16  years  ago,  attack  of  gout.  Pains  on  both  sides 
in  the  great  toe- joint,  in  the  left  knee  and  left  thumb.  Pains  occur  espe- 
cially at  5  P.M.  and  3  a.m.  These  attacks  were  repeated  during  three 
years,  up  to  1887,  after  which  the  patient  was  entirely  free  from  com- 
plaints. 

ad  3.— No  I.  D.  C. 

ad  4. — Stomach  always  unusually  good.  Preference  for  strongly 
peppered  and  sour  foods. 


CARCINOMA    OF    THE    STOMACH  187 

ad  6. — Since  November,  1899,  intolerance  for  meat.  Headaches 
after  eating-  meat  or  bread.  Since  then  has  lived  on  milk  and  soup.  In 
April,  1900,  first  pain  in  the  epigastrium,  and  that  particularly  after  eat- 
ing; sensation  ""as  if  a  stone  were  lying  in  the  stomach."  Since  then 
odorless  eructation,  no  vomiting.  Since  the  beginning  of  November,  1900, 
there  is  present  the  feeling  as  if  the  stomach  on  the  left  side,  underneath 
the  costal  arch,  becomes  erectile  and  hard;  with  it  "rolling,"  which,  when 
it  becomes  strong,  affords  relief.  There  might  be  appetite  for  meat,  but 
patient  fears  the  consequences. 

ad  7. — Distinct  gastric  tumor,  hard,  little  painful.     Stomach,  be- 
ing spontaneously  distended,  is  palpable.     Spleen  can  be  felt,  moderately 
tough ;  no  edema.     Hallux  valgus  on  both  sides  of  high  degree. 
Stomach  contents:  Stasis,  no  HCl. 

ad  8. — Beginning:  November,   1899. 

Status  presens:  November  22,  1900. 
Epicrisis :  Development  of  cancer  in  a  gouty  individual !  The  sig- 
nificance of  hallux  valgus  as  a  constitutional  defect  at  times  has  already 
been  pointed  out.  Initial  symptom  is  intolerance  of  meat.  Eating  of 
meat  provokes  headache,  later  on,  there  follow  the  subjective  and  objec- 
tive symptoms  depending  upon  constriction  of  the  pA^loinis. 

Case  18.— F.  B.,  52  years,  M. 

ad  3. — Of  I.  D.  C.  had  only  measles.  During  military  service  fell 
into  the  water  and  suffered  for  eight  months  from  articular  rheumatism. 
No  lues. 

ad  4. — Formerly  never  had  stomach  complaints.  Preference  for 
highly  seasoned  foods. 

ad  6. — In  December,  1899,  beginning  of  pressure  sensation  about 
%  to  %  hours  after  eating.  Duration:  about  one  hour.  No  vomiting; 
bitter  eructation  and  heartburn.  Anorexia;  particular  intolerance  for 
farinaceous  foods,  meat  and  sharply  seasoned  foods.  Constant  increase 
of  the  complaints.  Some  improvement  after  taking  soda  bicarb.  Percus- 
sion caused  pain  on  the  right  side,  posteriorly,  over  the  base  of  the  lung 
and  underneath  the  right  costal  arch. 

ad  7. — Tongue  slightly  coated.  Tumor-mass  on  the  left  side  in 
the  epigastrium ;  later  on,  friction  in  the  same  place  and  much  tenderness 
to  pressure.  Vomiting  only  toward  the  end.  Previous  to  death,  fecal 
vomiting  (containing  triple  phosphates!),  diarrheas.  Tongue  verv  drv. 
Chill,  five  days  before  death.  Traube's  space  narrowed;  on  the  left  side, 
posteriorly,  dulncss  from  the  angle  of  the  scapula,  respiratory  sounds 
weakened,  slightly  bronchial. 

Urine:  Since  1^  years  scanty,  much  sedim.  laterit. 

ad  8. — Beginning:  December,  1899. 

Status  presens:  December  19,  1900. 
Autops}  :  January  7,  1901. 
Duration:  1  year,  1  month. 

ad  9. — Autopsy  (Professor  Dr.  0.  Stoerk)  :  Diffuse,  ulcerating 
carcinoma    of   the    stomach,    especially    of   the    greater    curvature,    with 


188  TUMORS    OF    THE    ABDOMINAL    VISCERA 

diminution  of  the  gastric  lumen  ;  an  ichorous,  walled-off  abscess,  the  size 
of  a  head,  underneath  the  left  half  of  the  diaphragm,  between  stomach 
and  transverse  colon,  extending  on  the  right  up  to  the  suspensory  liga- 
ment of  the  liver.  Abscess  perforating  near  the  curvature  into  stomach 
and  colon,  so  that  there  is  a  communication.  Carcinomatosis  of  the  pa- 
rietal and  visceral  peritoneum,  metastases  in  the  liver,  in  the  retroperi- 
toneal and  inguinal  lymph-glands. 

Epicrisis:  As  in  Case  7,  so  also  here,  a  left-sided  subphrenic  abscess, 
which,  perforating  the  stomacli  and  colon,  established  a  gastro-intestinal 
fistula. 

Result:  Fecal  vomiting  with  triple  phosphate  crystals  and  ichorous 
diarrheas.  The  change  in  urination  noted  by  the  patient  IVo  years  prior 
to  death  (oliguria  with  copious  uric-acid  sediment)  probably  coincides 
with  the  development  of  cancer. 

Case  19.— W.  M.,  60  years,  M.     Coachman. 

ad  2. — Ten  j^ears  ago  inflannnation  in  joints  of  both  hands,  lasting 
three  weeks. 

ad  3.— No  I.  D.  C. 

ad  4. — Had  an  "excellent  stomach";  fat,  also,  was  tolerated  in 
large  quantities.     Preference  for  sour  and  hot  foods. 

ad  5. — Three  years  ago  was  treated  during  fourteen  days  for  morb. 
macules,  Werlhofii. 

ad  6. — In  November,  ]9()(),  vomited  blood,  filling  a  cuspidor,  with- 
out prodromes ;  simultaneous  black  coloration  of  the  stool.  After  this 
vomiting  of  blood,  pains  began.  Anorexia  since  the  end  of  January, 
1901  ;  disgust  for  meat.  Feeling  of  pressure  in  the  stomach  after  eating; 
pains  to  the  left  of  the  navel,  with  left  lateral  position  ;  the  point  of  pres- 
sure moves  the  width  of  three  fingers  to  the  left,  the  same  with  right  lat- 
eral position  to  the  right.  If  the  patient  eats  at  noon  the  pains  appear 
about  6  or  7  o'clock;  they  make  the  right  lateral  position  impossible. 
Chief  complaints  after  the  ingestion  of  meat. 

ad  7. — Tongue  not  much  coated.  Hard,  nodular  tumor  in  the  left 
half  of  the  epigastrium.  No  vomiting.  Hiccough  daily  in  the  fore- 
noon. Has  lost  15  kg  in  weight  during  the  last  two  months.  No 
edema. 

Stomach  contents:  HCl  absent,  lactic-acid  bacilli  abundant. 

ad  8. — Beginning:  November,  1900. 

Status  presens:  April  29,  1901. 
Duration:  6  months. 
Epicrisis:  The  joint  affection  occurring  at  the  age  of  50  might  be 
interpreted  as  a  metabolic  disturbance,  rather  than  a  pure  infectious  dis- 
ease. Relations  between  carcinoma  and  metabolic  anomalies!  As  is  fre- 
quently the  case,  so  also  here,  we  are  dealing  with  a  "stomach  athlete." 
A  rare  initial  symptom :  hematemesis.  The  right-sided  "painful  position" 
speaks  for  the  pylorus  as  the  place  of  origin. 


CARCINOMA    OF    THE    STOMACH  189 

Case  20.— J.  B.,  57  years,  M.     Porter. 

ad  1. — Father  died  at  TO  of  old  age.  oNIother  succumbed  to  some 
pulmonary  disease. 

ad  2. — Phthisical  habitus. 

ad  3. — No  I.  U.  C. ;  typhoid  (?)  at  9  years  of  age. 

ad   4. — Never  had  stomach  complaints. 

ad  5. — Always  led  a  regular  life,  "like  a  clock." 

ad  6. — In  December,  1900,  burning  in  the  gullet  after  eating, 
later  on  nausea  and  vomiting  after  every  meal.  Pain  in  the  region  of  the 
stomach  after  the  intake  of  solid  foods.  Rowels  regular  in  the  beginning, 
but  later  became  irregular,  hard.  In  May,  1901,  "coffee-ground"  vom- 
iting. In  June,  1901,  despite  visible  peristalsis,  not  much  pain. 

ad  7. — In  March,  1901,  the  patient  himself  became  aware  of  an 
enlargement  in  the  epigastrium,  which  seemed  to  become  erect  and  move, 
accompanied  by  gurgling.  Tumor  at  the  pylorus.  Visible  peristalsis  with 
hiccough.  Yellowish  coloration  of  the  face.  Distinct  retromalleolar 
edema.  "Coffee-ground"  vomiting  without  HCl,  with  presence  of  pure 
culture   of  lactic-acid  bacilli. 

ad  8. — Reginning:  December,  1900. 

Status  presens:  June  13,  1901. 
Duration :  6  months. 
Epicrisis:  The  initial  symptoms,  such  as  heartburn,  nausea  after  every 
meal,  etc.,  may  be  interpreted  in  many  ways.  They  gain  in  importance, 
however,  when  they  occur  in  an  individual  who  has  had  a  "strong  stomach" 
and  not  disappearing  very  soon.  In  such  cases  one  must  always  think  of 
gastric  cancer. 

Case  21. — F.  P.,  50  years,  M.    House  servant. 

ad   1. — Mother,  four  sisters  and  brothers  healthy. 

ad  3. — No  I.  D.  C.     Malaria  at  17,  since  then  always  healthy. 

ad  4. — Appetite  always  good  and  bowels  regular;  preference  for 
sour  and  spicy  foods. 

ad  6.^ — Loss  of  appetite  without  apparent  cause  since  January, 
1901,  particularly,  disgust  for  boiled  beef  and  fat.  Feeling  of  pressure 
after  eating  meat.  Since  that  time  constipation.  Since  then  has  lived 
on  sour  milk,  eggs,  brain  with  Ggg.  Since  February,  1901,  sour  eructa- 
tion, vomiting  at  first  only  after  drinking  cold  water,  but  later  also  after 
soup,  least  after  milk.  Recently  cramp-like  pains  in  the  region  of  the 
pylorus.  With  right  lateral  position  rather  severe  eructation,  vomiting 
lighter,  pains  more  severe. 

ad  7. — Early  in  August,  1901,  palpable  resistance  in  the  epigas- 
trium. Transverse  firm  tumor  as  thick  as  the  middle  finger.  No  edema. 
"Coffee-ground"  vomiting,  with  pure  culture  of  lactic-acid  bacilli. 

ad  8. — Reginning:  January,  1901. 

Status  presens:  August  6,  1901. 
Autopsy:  September,  1901. 
Duration  :  About  8  months. 


190  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  9. — Autopsy:  Constricting  infiltrating  carcinoma  of  the  py- 
lorus with  peritoneal  and  hepatic  metastases.  Slight  cicatricial  changes 
in  both  pulmonary  apices. 

Epicrisis:  Disgust,  especially  for  boiled  beef,  is  frequently  found  as  an 
initial  symptom,  and  in  cases  when  gastric  digestion  had  been  good  must 
be  considered  seriously.  The  vomiting  at  the  start  was  elicited  especially 
by  cold  water. 

The  localization  of  the  process  at  the  pylorus  is  indicated  by  the 
right  lateral  "painful  position,"  which  also  causes  exacerbation  of  eruc- 
tation and  vomiting. 

Case  22. — J.  B.,  58  years,  M. 

ad   1. — Father  and  mother  died  of  old  age. 

ad  3. — No  I.  D.  C.     Typhoid  at  16  years  of  age. 

ad  4. — Always  has  good  appetite,  bowels  regular. 

ad  5. — Always  healthy. 

ad  6. — In  beginning  of  October,  1901,  without  apparent  cause, 
immediately  after  noonday  meal,  violent  burning  pains  in  the  middle  of 
the  epigastrium,  with  heartburn.  Duration:  1^  hour;  thereafter  dizzi- 
ness and  vomiting  (mucoid,  dark,  sour).  Since  then,  if  he  eats  at  12 
o'clock,  has  burning  pains  at  about  2  or  2.30  p.m.  Appetite  still  good  in 
the  early  part  of  September,  1901.  When  in  pain  the  patient  doubles 
up,  and  with  his  hand  presses  against  the  region  of  the  stomach,  which 
alleviates  the  pain  somewhat.  Eructations  "like  rotten  wood."  He  is 
aware  of  splashing  sounds  earl}''  in  the  morning,  without  having  had  any- 
thing to  drink. 

ad  7. — Tongue  slightly  coated,  teeth  very  defective.  Tumor  in  the 
epigastrium,  with  occasional  gastric  rigidity.  No  edema.  After  test- 
breakfast,  1.3%  HCl.  Few  sarcinae.  Splashing  sounds  in  stomach  early 
in  the  morning,  on  a  fasting  stomach.  Vomiting  about  three  to  four 
hours  after  meals. 

ad  8. — Beginning:  Early  in  October,  1901. 
Status  presens :  November  4,  1901. 
Operation:  December  18,  1901. 
Duration:  21/)  months  (?). 

ad  9. — Operation  (Dr.  H.  Salzer)  :  Pylorus  and  pyloric  portion  of 
the  stomach-wall  changed  into  a  hard  tumor.  Greatest  length  at  the 
greater  curvature,  12  cm;  at  the  small  curvature,  8  cm.  Resection  of  the 
pylorus,  gastro-enterostomy.     Dismissed  as  cured  January  23,  1902. 

Anatomical  finding:  Infiltrating  carcinoma  of  the  stomach  superim- 
posed on  a  gastric  ulcer. 

Epicrisis:  For  the  purpose  of  differentiation  from  a  benign  stenosis  of 
the  pylorus  (HCl  sarcinae),  it  seems  to  me  important  that  the  stenosis 
has  developed  after  a  very  short  duration  of  stomach  symptoms.  This 
speaks  generally  for  malignancy  of  the  stenosis.  The  existing  painful 
attacks  are  to  be  interpreted  as  "colics  of  pyloric  stenosis." 

The  anatomical  finding  refers  to  a  chronic  ulcer  jis  the  basis  of  the 
cancer   formation.      Clinically,   there   is   not   the   slightest   evidence   of  a 


CARCINOMA    OF    THE    STOMACH  191 

chronic  ulcer.  Tliis  incongruity  is  found  so  often  as  almost  to  justify  the 
suspicion  that  the  changes  anatomically'  appearing  as  a  chronic  ulcer 
have  developed  in  the  course  of  the  cancer  development  (thrombosis?). 

Moreover,  in  this  case  there  was  for  a  long  time  persistence  of  HCl 
secretion,  which  is  commonly  accepted  as  characteristic  of  ulcer  carci- 
noma, although  there  is  no  compelling  reason  for  it. 

Case  23.— J".  N.,  42  years,  M.     Tailor. 

ad  1. — Father  died  at  H-i  of  old  age.     Mother  living  and  healthy. 

ad  3. — No  I.  D.  C. ;  scorbutus  (?)  at  13  years  of  age. 

ad  6. — Says  that  in  October,  1899,  he  spoiled  his  stomach  at  a 
death  wake ;  since  then  stomach  is  sensitive,  now  and  then  some  pressure 
in  the  stomach  and  constipation.  In  the  spring  of  1900  felt  exhausted, 
had  a  pale  ("j-ellow")  color.  Varying  appetite;  now  and  then  vomiting 
immediately  after  meals.  Ei*uctations  having  the  odor  of  decomposed 
eggs.  In  the  autumn  of  1900  a  "chronic  gastric  catarrh"  was  diagnosed. 
Karlsbad  cure,  followed  by  some  improvement.  During  the  course  of 
1901  no  vomiting;  in  the  autumn  of  1901  appearance  of  edema  in  the 
lower  extremities.  Since  appearance  of  gastric  symptoms  patient  no 
longer  has  headaches,  which  he  had  before.  Since  Fcbiiiary,  1900,  sensa- 
tion of  pressure  on  both  sides  along  the  costal  arches  and  in  the  middle 
of  the  epigastrium ;  now  and  then  pains  in  the  back.  Pain  in  stepping 
Avith  the  left  leg,  pain  being  behind  the  internal  malleolus  and  in  the 
popliteal  space;  entire  leg  strongly  edematous  (thrombosis  of  the  left 
crural  vein). 

ad  7. — Lingual  mucosa,  especially  in  its  middle  portion,  smooth, 
atrophic.  Soft  carcinomatous  nodules  can  be  felt  in  the  epigastrium. 
Pulse  12-i,  small,  bounding.  Loud,  raspy,  systolic  murmur  audible  over 
the  sternum.  Emaciation  covered  up  by  diffuse  dropsical  swellings ;  ex- 
treme pallor.  Hemoglobin  12%,  numerous  normoblasts. 

December  9. — After  defecation,  severe  pains  in  the  belly,  collapse, 
died  at  midnight. 

ad   8. — Beginning:  October,   1899. 

Status  presens:  December  2,  1901. 
Autopsy:  December  10,  1901. 
Duration :  2  years,  2  months. 

ad  9. — Autopsy  (Professor  Dr.  0.  Stoerk)  :  Polypoid  carcinoma, 
being  the  size  of  a  man's  fist,  in  the  pyloric  region,  with  papillary  sur- 
face. Recent  perforation  toward  the  base  of  the  liver  with  beginning 
diffuse,  fibrinous  peritonitis.  Escape  of  stomach  contents  into  belly  cav- 
ity (pure  culture  of  streptococci  in  the  peritoneal  cavity).  Severe  gen- 
eral anemia. 

Epicrisis:  Wherever  a  single  dietetic  error  is  accused  of  being  the 
cause  of  protracted  gastric  ailments,  the  greatest  doubt  should  be  main- 
tained. 

Very  frequently  these  are  cases  of  gastric  cancer  in  which  a  dietetic 
error  probably  precipitates  the  appearance  of  a  latent  carcinoma.  The 
diagnosis  of  "chronic  gastric  catarrh"  should  always  be  made  with  great- 


192  TUMORS    OF    THE    ABDOMIXAI.    VISCERA 

est  scepticism  and  after  careful  deliberation;  for  how  often  a  gastric 
cancer  is  concealed  behind  this  pseudonym ! 

A  "chronic  gastric  catarrh"  is  anatomically  very  frequent,  but  clin- 
ically enormously  rare  as  the  sole  cause  of  severe  or  even  painful  gastric 
symptoms. 

The  disappearance  of  a  chronic  cephalalgia  with  the  appearance  of 
gastric  cancer  is  interesting. 

This  case  illustrates  the  "hydropic-anemic"  type  of  gastric  cancer; 
the  same  is  always  accompanied  by  tachycardia  and  very  often  also 
conspicuous,  raspy,  systolic  murmurs,  especially  over  the  sternum,  which 
may  be  easily  referred  to  the  pericardium.  Autopsies  offer  no  explana- 
tion ;  they  are  probably  only  anemic  murmurs. 

Case  24.— W.  F.,  42  years,  F. 

ad  1. — Father  living  and  healthy;  mother  died  a  year  ago  of 
gastric  cancer. 

ad  3.— No  I.  D.  C. 

ad  4. — Fifteen  years  ago  had  stomach  trouble,  lasting  one  year. 
Stabbing  pains  on  the  left  side,  underneath  the  costal  arch,  with  great 
sensitiveness  to  pressure.  Increase  of  the  complaints  after  ingestion  of 
foody  frequently  vomiting  two  hours  after  meals.  These  symptoms  dis- 
appeared entirely  after  one  year. 

ad  5. — Menstruations  began  at  15.     Had  7  confinements. 

ad  6. — Since  the  beginning  of  November,  1900,  constant  gastric 
pains  and  vomiting.  Anorexia.  Disgust  for  meat;  could  eat  nothing  but 
milk.   The  patient  herself  felt  a  tumor,  which  increased  rapidly  in  9  weeks. 

ad  7. — Tumor  the  size  of  a  walnut  in  the  umbilical  depression.     No 
edema.     Color  of  face,  pale.     Transient  temperatures  up  to  38°  C. 
Stomach  contents:  Abundant  lactic-acid  bacilli.     HCl  absent. 

ad  8. — Beginning:  November,  1900. 

Status  presens:  December  7,  1901. 
Operation:  December  13,  1901. 
Duration :  About  1  year,  1  month. 

ad  9. — Operation:  Firm  tumor  the  size  of  a  hen's  egg  belonging 
to  the  p3'lorus  (Histol.  cylindrical  cell  cancer).  Transverse  mesocolon 
grown  to  the  tumor. 

Epicrisis:  Mother  and  daughter  taken  with  gastric  cancer  in  rapid 
succession.  The  gastric  affection  of  15  years  ago  ma^^  probably  be  diag- 
nosed even  at  a  subsequent  date  as  an  ulcer.  The  occasional  rises  in  tem- 
perature must  be  referred  to  the  carcinoma,  in  fact  it  Is  advisable  when 
there  is  suspicion  of  gastro-intestinal  neoplasms  to  pay  attention  to  the 
behavior  of  the  temperature. 

Case  25. — H.  J.,  36  years,  M.    Laborer. 

ad   1. — Parents  living  and  healthy. 

ad  4. — Always  had  a  good  stomach,  preference  for  sour  and  spicy 
foods ;  eructations  for  quite  some  time  past.  Since  six  or  seven  years 
constipation  and  hemorrhoids. 


CARCINOMA    OF    THE    STOMACH  193 

ad  6. — Since  January,  1900,  often  has  pain  and  pressure  in  stom- 
ach after  catin^r;  these  disturbances  started  without  cause.  Often  vom- 
iting (immediately  after  ingestion  of  food)  and  belching  of  odorless 
gases.  Since  December,  1900,  the  abdomen  began  to  enlarge.  Gastric 
pains,  especially  1  to  ll/i  hours  after  meals;  often  epigastric  pains  at 
night;  vomit  ameliorates  condition.  Pain  anteriorly  at  tiie  xiphoid  proc- 
ess and  posteriorly  at  a  point  corresponding  to  the  12th  dorsal  vertebra. 
Tenderness  to  pressure  in  right  lumbar  region.  (Autopsy:  right-sided 
hydronephrosis  as  a  result  of  cancerous  infiltration  of  the  right  ureter.) 
Since  two  days  ago  slight  difficulty  in  deglutition.  Appetite  not  so  very 
bad ;  yet  onl}'  milk  is  tolerated;,  one  or  two  spoonfuls  of  soup,  water  in 
teaspoonfuls,  otherwise  immediate  vomiting.  It  takes  the  patient  half 
a  day  to  drink  one-half  litre  of  beer.  A  mouthful  seems  too  much,  comes 
back  immediately. 

ad  7. — Ascites.  Nodular  tumor-masses  in  the  left  half  of  the  epi- 
gastrium;  spontaneous  alterations  of  same  in  position,  change  in  distinct- 
ness of  palpation.  Umbilicus  infiltrated  with  cancer  (since  the  beginning 
of  the  disease  hardening  and  enlargement  noticed  around  the  umbilicus, 
gradually  become  larger  and  harder).  Severe  retromalleolar  edema.  Bi- 
lateral pleural  effusion.     Pulse  44<,  threadlike. 

ad  8. — Beginning:  January,  1900. 

Status  presens:  January  4,  1902. 
Autopsy:  January  14,  1902. 
Duration:  2  3'ears. 

ad  9. — Autopsy  (Professor  Dr.  H.  Alhrecht)  :  Infiltrating  scirrhus 
of  the  stomach  with  considerable  diminution  in  size  of  same  and  uniform 
hypertrophy  of  the  muscularis.  Secondary  carcinoma  of  the  entire  peri- 
toneum with  complete  atrophy  of  the  large  omentum  and  multiple  con- 
strictions of  the  large  bowel.  Coprostatic  ulceration  of  the  cecum,  with 
perforation  of  same  in  three  places,  the  size  of  a  lentil.  Serofibrinous 
peritonitis.  Stenosis  of  the  right  ureter,  due  to  cancerous  infiltration 
and  right-sided  hydronephrosis.  Cancerous  infiltration  of  the  skin  of 
the  umbilical  region. 

Ejncrisis:  A  typical  example  of  that  type  of  gastric  cancer  which 
leads  to  contraction  of  the  stomach  and  early  ascites.  Precisely  these 
cases  not  infrequently  run  their  course  with  umbilical  metastases,  a  find- 
ing which  permits  of  the  most  rapid  and  most  simple  differential  diag- 
nosis from  tuberculosis  of  the  peritoneum.  Inability  of  the  stomach  to 
retain  even  very  small  quantities  of  fluids  is  characteristic.  In  order  to 
consume  one-half  litre  of  liquids  the  patient  requires  half  a  day!  The 
unaccountable  appearance  of  gastric  symptoms,  where  previously  there 
was  a  good  stomach,  is,  as  always,  worthy  of  attention.  Ulcerlikc  pains 
accompany  the  process  of  the  disease.  Pronounced  bradycardia ! 
Pulse  44. 

As  a  rare  complication  of  a  gastric  cancer  there  develops  (through 
cancerous  infiltration  of  the  right  ureter)  a  right-sided  hydronephrosis 
with  tenderness  on  pressure  in  the  right  kidney  region. 


194  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  26. — J.  Z.,  59  years,  M.    Prison  guard. 

ad  2. — Articular  rheumatism  for  19  months  at  the  age  of  47,  had 
started  in  the  joint  of  the  great  toe;  fever  for  one  month. 

ad  3.— No  I.  D.  C. 

ad  4. — Always  a  good  stomach;  preference  for  strongly  seasoned 
foods. 

ad  5. — Moderate  in  drinking  and  smoking. 

ad  6. — Since  January,  1900,  nausea  and  sour  eructations.  Since 
September,  1901,  severe  gastric  pain,  mostly  about  4  o'clock  in  the  after- 
noon and  at  night.  The  pain  often  begins  in  the  lower  abdominal  region 
on  the  left,  and  extends  to  the  xiphoid  process ;  belching  brings  relief. 
During  an  attack  of  pain  right  lateral  decubitus  is  tolerated  badly, 
dorsal  decubitus  is  impossible ;  vision  is  poor  during  attack  of  pain. 

ad  7. — Tongue  much  indented.  Stomach  distended  like  an  air- 
cushion,  particularly  in  its  right  pyloric  portion.  Hard,  nodular  tumor 
of  the  pylorus.  For  the  past  14  days  very  copious  vomiting  in  the 
evening,  formerly  at  evening  only  a  feeling  of  pressure  and  regurgitation 
of  "sour  water."  Eructation  having  the  odor  of  decomposed  eggs 
(SH2).  During  the  attack  of  pain,  erectile  feeling  in  the  region  of  the 
pylorus,  pupils  somewhat  contracted,  reacting  slowly ;  P.  T.  R.  increased. 
No  edemas.     Pulse,  56.     HCl  negative  after  test-breakfast. 

ad  8.— Beginning:  January,   1900. 

Status  presens:  January  15,  1902. 
Operation :  February  25,  1902. 
Duration:  2  years,  1  month. 

ad  9. — Operation  (Dr.  H.  Salzer).  Firm  tumor  at  the  pylorus  the 
size  of  a  small  apple.  Typical  resection  of  the  pylorus  after  Billroth  (1). 
Dismissed  as  cured,  March  15,  1902. 

Epicrisis:  This  is  a  type  of  the  "fibrous"  gastric  cancer  limited  to 
the  pylorus  and  producing  much  constriction;  bradycardia  (pulse  56) 
as  a  frequent  accompanying  manifestation  in  these  cases.  The  history 
reveals  no  infectious  diseases  of  childhood.  At  47  years  of  age  the 
patient  had  a  joint  affection  which,  in  view  of  the  fact  that  it  started 
in  the  joints  of  the  great  toe,  and  the  further  fact  that  infectious  articu- 
lar rheumatism  almost  never  occurs  for  the  first  time  at  this  age  (47 
years),  may  be  looked  upon  as  "gouty." 

The  functional  ability  of  the  stomach  had  been  a  very  good  one  before 
the  disease. 

Eructation  of  sulphurous  fluids  in  the  presence  of  achlorhydria  is 
alwaj's  highly  suspicious  of  a  constricting  cancer  of  the  pylorus. 

Case  27.— F.  P.,  43  years,  M.    Servant. 

ad  3. — Had  smallpox  and  measles;  at  the  age  of  15  had  malaria 
for  five  months. 

ad  4. — Alwa3's  had  a  sensitive  stomach,  fat  in  particular  being 
badly  tolerated. 

ad  6.- — In   November,    1901,   appearance   of   anorexia;   subsequent 


CARCINOMA    OF    THE    STOMACH  195 

improvement  of  appetite.  Even  now  has  appetite  for  meat,  no  pains. 
Meat  is  tolerated.  With  right  lateral  decubitus  there  is  burning  as  high 
up  as  the  throat.      The  patient  nmst  lie  on  his  left  side. 

ad   7. — Tumor    at    the    pylorus.      Visible    (painless)    gastric    peri- 
stalsis.     Three   to   four  hours   after  meals   there   is   vomiting,   light   and 
gushlike  (having  set  in  during  past  three  months).     No  edemas.     HCl 
absent ;  sarcina-  in  addition  to  lactic-acid  bacilli, 
ad  8. — Beginning:   November,    1901. 

Status  presens :  January  16,  1902. 
Autopsy:  March  9,   1902. 
Duration:  4  months(.'*). 
ad  9. — Autopsy  (Professor  Ur.  A.  Ghon)  :  Scirrhus  of  the  pylorus, 
probably  an  ulcer  base,  with  stenosis.     Flat  scirrhus  infiltration  of  the 
peritoneum  and  omentum. 

Epicrisis:  Here  we  have  the  unusual  case  of  a  "stomach  weakling" 
contracting  cancer  of  the  stomach.  This  is  much  more  frequent  in 
"stomach  athletes,"  so  much  so  that  one  is  often  tempted  to  say :  Gastric 
cancer  is  a  disease  of  "healthy  people." 

The  anatomist  suspects  a  pre-existing  ulcer,  clinically  there  is  no 
typical  history  of  an  ulcer,  yet  it  might  be  possible  that  the  sensitive- 
ness of  the  stomach,  extending  over  many  years,  has  some  connection 
with  a  latent,  cicatricized  ulcer. 

Edemas  do  not  usually  appear^ — not  even  terminally — in  connection 
with  fibrous  cancer  of  the  pylorus  and  copious  vomiting.  The  profuse 
vomiting  leads  to  desiccation  of  the  organism. 

The  tolerance  for  meat  remaining  up  to  within  a  few  months  of  death 
is  remarkable. 

Case  28. — J.  N.,  51  years,  M. 

ad  2. — A  weak  individual. 

ad  3. — No  infectious  disease. 

ad  4. — Constipated  for  past  seven  years. 

ad  5. — No  alcohol;  heavy  smoker  (pipe). 

ad  6. — In  November,  1901,  loss  of  appetite  and  slight  pains  in 
the  upper  abdominal  region ;  formerly  sour  eructations  now  and  then. 
While  carrying  a  trunk,  pressed  same  against  the  belly,  producing  sharp 
pains  in  the  epigastrium.  Epigastrium  somewhat  tender  on  pressure, 
otherwise  no  pain.     Great  thirst  during  past  five  weeks. 

ad  7. — Tongue  heavily  coated.  Epigastrium  distended,  especially 
on  the  left  side,  where  there  is  tensely  elastic  consistence,  loud  splashing. 
Cancer  nodules  palpable  in  the  epigastrium.  Waxy  yellow  color  of  the 
face.     No  edema.     Loud  venous  hums. 

Stomach  contents:  HCl  negative,  enormously  abundant  lactic-acid 
bacilli. 

ad  8. — Beginning:   November,    1901. 

Status  presens :  March  3,  1902. 
Duration:  4*  months(?). 
Epicrisis:  Great  thirst  is  not  infrequently  met  with  in  gastric  cancer; 


196  TUMORS    OF    THE    ABDOMINAL    VISCERA 

the  symptom  deserves   consideration   in   so   far  as   gastric   neuroses   are 
frequently  accompanied  by  a  strikingly  diminished  feeling  of  thirst. 

A  trauma,  pressing  against  a  trunk,  in  this  case  elicited  epigastric 
pain,  evidently  at  a  time  when  the  carcinoma  already  existed  (November, 
1901).  It  is  indeed  not  rare  that  traumas  permit  neoplasms,  hitherto 
more  or  less  latent,  to  manifest  themselves. 


Case  29.— F.  W.,  65  years,  M. 

ad  3. — No  I.  D.  C.     In  1887  left-sided  pleurisy  for  six  weeks. 

ad  4. — Five  years  ago  loss  of  appetite  with  sour  eructation  and 
vomiting  after  ingestion  of  meat.  A  swelling  is  said  to  have  existed 
between  the  left  costal  arch  and  the  navel,  but  which  subsequently 
disappeared;  at  the  same  time  pain  posteriorly  in  left  lumbar 
region. 

ad  5. — Otherwise  always  health3\ 

ad  6, — Since  November,  1901,  sour  burning  eructations.  Vomit- 
ing, especially  two  to  three  hours  after  eating,  frequently  also  at  3  a.m. 
Constipation  since  this  illness  started.  Often  a  sensation  of  "rolling" 
in  the  stomach.  Appetite  would  be  good,  but  he  was  afraid  to 
eat. 

ad  7. — Doughy,  firm  consistence  at  a  place  corresponding  to  the 
pylorus,  of  varying  distinctness.  Left  half  of  the  epigastrium  distended 
with  meteorism.  Evidence  of  atelectasis  posteriorly,  lower  left  side, 
traces  of  retromalleolar  edema. 

Stomach  contents:  Traces  of  HCl,  severe  stagnation,  abundant  sar- 
cinae,  besides  lactic-acid  bacilli. 

ad  8. — Beginning:  November,   1901. 

Status  presens:  March  17,  1902. 
!  Operation:  March  23,  1902. 

Duration :  About  5  months. 

ad  9.— Operation  (Docent  Dr.  P.  Albrecht)  :  Carcinoma  of  the 
stomach,  corresponding  to  the  posterior  portion  of  the  pylorus  and  the 
posterior  wall  of  the  stomach  along  the  lesser  curvature ;  at  the  latter 
place  adherent  to  the  left  lobe  of  the  liver;  wall  of  the  stomach  at  this 
site  shows  cicatricial  changes;  contracted;  probably  cancer  in  a  cicatrix. 
Gastro-enterostomy.     Dismissed  as  cured  April  7,  1902. 

Epicrisis :  The  previous  history  of  the  case  would  seem  to  justify  the 
opinion  of  the  operator  that  the  carcinoma  was  superimposed  on  an  ulcer 
base. 

In  1897,  five  years  prior  to  surgical  interference,  there  was  present 
a  disease  which,  in  view  of  the  then  existing  swelling,  anorexia,  meat 
intolerance,  etc.,  could  easily  have  been  mistaken  for  a  carcinoma.  It 
is  highly  probable  that  it  was  an  ulcer  tumor  of  inflammatory  origin. 
Evidences  of  atelectasis  in  the  region  of  the  left  lower  lobe  are  not 
rarely  met  with  in  connection  with  gastric  cancer,  and  very  likely  are 
explained  by  the  high  position  of  the  left  half  of  the  diaphragm  as  a 
result  of  g-astric  meteorism. 


CARCINOMA    OF    THE    STOMACH  197 

Case  30. — J.  R.,  50  years,  M.    Clerk. 

ad   1. — Father  reached  high  old  age. 
ad  3.— No  I.  D.  C. 

ad  4. — Gastric  comphiints  for  past  three  years. 
ad  5. — Always  was  healthy;  transient  sciatica-like  pains  in  188.5. 
ad  6. — Since  autumn  of  1901,  increase  of  gastric  complaints; 
since  then  anorexia  and  severe  emaciation.  At  present  cramp-like  pains, 
especially  after  eating,  radiating  from  the  epigastrium  into  the  left 
lumbar  region  and  upward  along  the  sternum ;  at  the  same  time  in- 
creased tension  in  the  left  half  of  the  epigastrium  (gastric  peristalsis). 
Severe  sensation  of  pressure  after  eating  meat,  also  pains  in  epigastrium 
when  straining  hard  at  stool. 

ad  T. — Tongue  not  coated.  Large  cylindrical  tumor  on  the  left 
side,  below  the  costal  arch.  Frequent  hiccough.  No  edemas.  Spleen 
distinctly  palpable. 

Stomach  contents:  Very  abundant,  short  lactic-acid  bacilli, 
ad  8. — Beginning:  Autumn,  1901. 

Status  presens :  June  2,  1902. 
Operation:  June  8,  1902. 
Autopsy:  June  10,  1902. 
Duration:  About  9  months(.''). 
ad  9. — Autopsy  (Docent  Dr.  J.  Bartel)  :  Carcinoma  of  the  pylorus 
encroaching  on  the  lesser  curvature  upward  almost  to  the  cardia,  down- 
ward to  the  middle  of  the  greater  curvature.     Resection  of  almost  entire 
stomach. 

Epicrisis:  This  case  affords  occasion  for  pointing  out  the  fact  that 
infectious  diseases  of  childhood  in  particular  are  strikingly  seldom  re- 
corded in  the  history  of  cancer  patients.  There  will  be  repeated  oppor- 
tunities for  emphasizing  this  point. 

"Colics  of  pyloric  stenosis"^-  prevail  in  the  ensemble  of  subjective 
phenomena.  "Lactic-acid  bacilli"  are  present  in  abundance,  but  not  in 
the  usual  form  of  long  threads,  rather  as  Gram-positive  rod-shapes 
("dwarf  forms"),  a  morphological  type  occasionally  also  found  in  cul- 
tures on  sugar  agar,  particularly  when  the  nutritive  medium  is  dry. 
The  colonies  are  then  circular  and  do  not  exhibit  the  t^'pical  curled 
border  reminding  one  of  anthrax  colonies. 

Case  31.— H.  J.,  38  years,  M.    Miner. 

ad  2. — Tubercular  habitus. 

ad  3. — No  I.  D.  C.     At  17  had  pneumonia  for  5  weeks. 

ad  5. — Frequent  sufferer  from  pulmonary  catarrh  and  morning 
sweats   (autopsy:  lungs  normal). 

ad  6. — June,  1900:  Pressure  in  stomach  after  eating  meat,  loss  of 
appetite;  mild  constipation.  Epigastrium  tender.  Condition  became 
improved. 

'-  See  page  70. 


198  TUMORS    OF    THE    ABDOMINAL    VISCERA 

December,  1901 :  Repetition  of  same  manifestations.  Condition  much 
improved. 

April,  1902:  Tho,se  around  him  became  aware  of  the  ill-smelling 
vomitus.  Bowel  movements  improved  the  appetite.  Vomiting  two  to  three 
hours  after  ingestion  of  food.  No  tenderness  to  pressure  under  the  left 
costal  arch. 

Beginning  of  May,  1902:  Copious  discharge  of  mucus  at  stool. 

June  10,  1902:  Sudden  violent  cramplike  pains  around  the  umbilicus, 
abdomen  very  rigid,  dulness  in  the  flanks,  tenderness  on  pressure  (au- 
topsy: perforating  peritonitis). 

ad  7. — Tongue  moist,  somewhat  coated.  A  hard,  nodular  tumor- 
mass  can  be  felt  under  the  left  costal  arch,  but  only  with  patient  in  right 
lateral  position.  Liver  larger  and  harder  (autopsy:  fatty  liver).  Severe 
edema  of  right  lower  extremity.     No  vomiting,  hardly  any  eructation. 

Withdrawal  of  stomach  contents  3Melds  fecal  content  with  bacterial 
\egetations. 

Blood:  •i,.500  leucoc3ftes.      Hemoglobin,  40 'X  . 
ad  8. — Beginning:  June,  1900. 

Status  prescns:  June  5,  1902. 
Autopsy:  June  11,  1902. 
Duration :  About  2  years, 
ad  9. — Autopsy   (Professor  Dr.  O.  Stoerk):  Extensive  carcinoma 
of  the  greater  curvature  in  the  fundus  of  the  stomach  and  wide  perfora- 
tion  into   the   splenic   flexure.      Recent   perforation   of  the   colon   in   this 
region   through   its   wall   infiltrated   with   carcinoma   into   the   abdominal 
cavity  with  beginning  peritonitis.     Metastatic  infiltration  of  the  omen- 
tum ;  here  and  there  liver  metastases.     Fatty  infiltration  of  the  liver  of 
high  degree. 

Epicrisis:  Transient  improvements  in  the  gastric  complaints,  as  in 
this  case,  do  not  belong  to  the  rare  occurrences  in  the  course  of  a  gastric 
cancer.  Ignorance  of  this  fact  may  permit  them  to  mislead  one,  causing 
the  abandonment  of  suspicion,  probably  correct  in  the  first  place.  It 
must  never  be  forgotten  that  the  functional  disturbances  of  the  organ, 
occurring  in  connection  with  gastric  cancer,  are  in  many  ways  not  directly 
due  to  the  cancer  as  such,  but  are  brought  about  through  pyloric  steno- 
sis, chronic  gastritis,  constipation,  etc.  These,  however,  are  variable  and 
may  show  improvements.  Thus,  the  pyloric  stenosis  may  become  less 
through  ulceration  of  the  constricting  tumor,  the  chronic  gastritis  and 
the  constipation  are  partly  amenable  to  therapy. 

Thus  we  have  here  also  the  statement  of  the  patient  that  the  appetite 
improved  wdth  the  occurrence  of  diarrheas. 

Spontaneous  diarrhea  is  not  a  frequent  occurrence  in  gastric  cancer; 
if  accompanied  by  copious  discharge  of  mucus,  as  in  the  case  at  hand, 
they  w^ould  suggest  the  possibility  of  a  secondary  participation  on  part 
of  the  colon  (gastro-colonic  fistula)  ;  the  same  holds  good  of  fecal  vomit- 
ing with  the  microscopic  finding  of  bacterial  vegetation.  Only  in  severely 
ulcerating  soft  gastric  cancer  is  the  latter  occasionally  met  with  without 
the  existence  of  a   communication  with  the  bowel.      Strange,  yet  easily 


CARCINOMA    OF    THE    STOMACH  199 

explained  by  tlic  discovery  of  a  gastro-colonic  fistula,  was  in  this  case  the 
inability  to  obtain  a  clear  reflow.  Diffuse  uniform  enlargement  of  the 
liver  with  moderate  increase  in  consistence  may  also  be  due  to  fatty 
infiltration. 

Case  32. — I.  E.,  68  years,  M.    Coppersmith, 
ad  3— No  I.  D.  C. 

ad  5. — Always  was  healthy. 

ad  6. — Since  June,  1901,  diminished  appetite.  December,  1901 : 
intolerance  for  cooked  beef  and  strongly  seasoned  foods;  since  has  no- 
ticed a  tumor  in  the  abdomen,  which  is  painful  only  on  pressure;  since 
this  time  there  often  is  eructation,  no  vomiting.  Severe  emaciation  of 
late. 

ad  8.^ — Nodular  tumor-mass  in  the  epigastrium.  Pronounced  pul- 
.satory  vibration  of  same,  disappearing  entirely  in  the  left  lateral  posi- 
tion.    Edemas  existed  formerly  when  the  patient  was  walking  about. 

Stomach  contents:  HCl  negative,  vomitus  contained  blood,  abundant 
lactic-acid  bacilli. 

ad  9. — Beginning:  June,  1901. 

Status  presens :  June  8,  1902. 
Duration:  About  1  year. 
Epicrisis:  The  disappearance  of  the  intense  pulsatory  vibration  in  the 
epigastrium  in  the  left  lateral  position  is  explained  by  the  displacement 
of  the  movable  epigastric  tumor-mass  belonging  to  the  stomach,  which 
transmits  aortic  pulsation  to  the  belly-wall  only  when  the  patient  is  lying 
on  his  back.  If  the  tumor-mass  were  firmly  attached  rctropcritoneally  the 
lateral  position  w^ould  produce  no  change. 

The  edemas   in  this   case   are  latent ;   they  have   regressed   since  the 
patient   remains  in  bed. 

Case  33.— G.  B.,  63  years,  M. 

ad  3. — Thirty  years  ago  had  a  left-sided  pleurisy,  lasting  8  days. 

ad  4. — Always  had  a  very  good  appetite. 

ad  5. — Always  healthy. 

ad  6. — Beginning  of  complaints,  June  26,  1902;  pressure  in  the 
region  of  the  stomach,  located  on  the  right  side,  especially  after  ingestion 
of  food.  Symptoms  became  aggravated  during  the  following  two  months. 
Appetite  at  the  start  perfectly  good,  even  meat  being  well  tolerated. 
No  eructations.  Bowels  regular.  Two  months  later  anorexia  and  belch- 
ing of  SHj.  Pressure  in  stomach,  particularly  after  intake  of  evening 
meal,  lasting  until  2  a.m.,  pains  radiating  into  both  hypochondriac  re- 
gions. Great  intensity  of  pains  with  left  lateral  position.  Dorsal  de- 
cubitus tolerated  best.  Of  late  the  patient  can  partake  only  of  soup 
and  eggs. 

ad  7. — Tumor  as  big  as  an  apple  in  the  right  half  of  the  epigas- 
trium, demarcation  from  liver  not  possible  (surgical  diagnosis:  cyst.''). 
Pigmented  spots  on  mucous  membrane  of  both  cheeks. 

Stomach  contents:  HCl  negative;  abundant  lactic-acid  bacilli. 


200  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  8. — Beginning:  June,  1902. 

Status  presens :  October  22,   1902. 
Operation:  November  1,  1902. 
Autopsy:  November  4,  1902. 
Duration :  About  5  months, 
ad  9. — Operation    (Docent    Dr.    D.    Pupovac)  :    Large    cancerous 
tumor  on  the  posterior  wall  of  the  pylorus,  adherent  to  the  liver,  pancreas 
and  transverse  colon. 

Autopsy:  Confirmation  of  above  finding  (disintegrating  medullary 
carcinoma). 

Epicrisis:  Prolonged  SH2  fermentation  (eructation  giving  the  odor 
of  "rotten  eggs")  is  always  a  sign  of  an  organic  lesion,  and  very  fre- 
quently coincides  with  the  presence  of  sarcina  ventriculi,  upon  which  in 
my  opinion  this  kind  of  gastric  fermentation  depends  in  most  cases.  It 
is  above  all  in  benign  pyloric  constrictions  succeeding  ulcer  of  the  stom- 
fich  that  there  is  subjective  complaint  of  SH2  and  objective  finding  of 
sa.rcina  ventriculi. 

However,  malignant  stenosis  also  may  be  accompanied  by  the  same 
subjective  and  objective  finding. 

The  aggravating  effect  on  the  pain  with  left  lateral  position,  though 
the  process  is  localized  at  the  pylorus,  is  worth}'  of  note.  It  is  conceiv- 
able that  the  gastro-hepatic  adhesions  in  this  case  play  an  essential  part. 

Case  34.— M.  W.,  59  years,  M. 

ad   4. — Appetite  formerly  always  good. 

ad  6. — Since  November,  1901,  anorexia  and  fre(juent  eructation  of 
"sour  water" ;  no  vomiting.  Had  to  be  careful  in  his  diet  during  the 
past  weeks.  Three  weeks  ago  there  began  "internal"  pains  in  the  left 
half  of  the  epigastrium;  14  days  ago  the  skin  in  this  locality  became 
reddened  and  in  the  course  of  a  few  days  there  developed  a  swelling  as 
big  as  a  fist,  bulging  outwardly.  Frequent  attacks  of  dizziness,  severe 
emaciation  of  late. 

ad  T. — Bulging,  the  size  of  a  fist,  in  the  left  half  of  the  epigas- 
trium, belonging  to  the  abdominal  wall,  protruding  on  coughing,  fluctu- 
ating distinctly  in  one  place;  no  respiratory  movability.  Distinct  thrill 
with  pulsation.  Skin  in  bulging  area  firmly  infiltrated,  hot,  red ;  edema 
in  the  neighborhood.  Over  the  top  of  the  swelling  a  high  tympanitic 
sound,  which  disappears  in  lateral  position  ;  splashing  audible  and  palpa- 
ble here  and  there  on  percussion.  Traces  of  retromalleolar  edema.  Slight 
elevation  of  body  temperature. 

ad  8. — Beginning:  November,  1901. 

Status  presens:  November  11,  1902. 
Operation:  November  13,  1902. 
Autopsy:  November  18,  1902. 
Duration :  About  1  year. 

ad  9.- — Autopsy  (Professor  Dr.  A.  Ghou)  :  Putrificd  and  ulcer- 
ating carcinoma  of  the  lesser  curvature  of  the  stomach,  near  the  p^dorus, 
with  constriction  of  the  pyloric  portion  ;  adhesion  of  the  lesser  curvature 


CARCINOMA    OF    THE    STOMACH  201 

with  the  border  of  the  left  lobe  of  the  liver  and  perforation  of  the 
carcinoma.  Putrifying,  subphrenic  abscess  in  the  area  of  the  left  lobe 
of  the  liver  and  the  spleen.  Putrifying  phlegmon  of  the  retroperitoneal 
connective  tissue  of  the  left  side  of  the  abdomen  and  testicle.  Arterio- 
sclerosis of  high  degree.     Aspiration  of  the  subphrenic  abscess. 

Epicrisis:  In  this  case  ^^  we  were  dealing  with  a  subpiirenic,  gas- 
containing  putrefactive  process  in  the  epigastrium  preparing  to  dis- 
charge outwardly,  emanating  from  a  gastric  tancer.  Hasty  examination 
might  in  such  cases  easily  lead  to  the  diagnosis  of  abscess  of  the  abdom- 
inal wall,  in  this  way  overlooking  the  more  deeply  seated  origin. 

Case  35. — L.  F.,  49  years,  M. 

ad   1. — Father  and  mother  died  of  old  age. 

ad  3. — In  1891  pain  in  limbs  and  head,  with  fever  ("influenza"). 

ad  4). — In  1893,  10  j-ears  ago,  on  getting  up  in  the  morning  very 
profuse  vomiting  of  red  blood;  gastric  ulcer  was  assumed  present.  Black 
coloration  of  stools.  No  gastric  pains.  Cured  in  8  weeks.  Patient 
then  remained  healthy  until  autumn  of  1899.     Preference  for  sour  foods. 

ad  5. — In  autumn  of  1899  repeated  gastric  complaints,  feeling  of 
pressure  about  one  hour  after  meals  and  moderate  acid  eructations. 
Particular  intolerance  for  potatoes  and  cereal  foods.  Anorexia.  Com- 
plaints disappeared  only  in  March,  1900.  From  the  autumn  of  1900 
to  ]\Iarch,  1901,  and  again  from  the  end  of  1901  to  the  early  part  of 

1902,  repetition  of  the  same  SA^nptoms.  In  spring  of  1902  quite  well 
again. 

ad  6. — November,  1902,  beginning  of  anorexia,  accompanied  by  a 
constant  feeling  of  fulness  in  the  stomach.     No  vomiting.     In  January, 

1903,  "gastric  catarrh"  was  diagnosed  and  Karlsbad  cure  prescribed. 
As  long  as  he  took  the  cure  had  to  vomit  profusely  in  the  evening,  the 
vomitus  being  like  coffee-grounds.  After  8  days  stopped  drinking  Kai'ls- 
bad  water  and  the  vomiting  ceased.  During  the  painful  attacks  the 
right  lateral  decubitus  is  badly  tolerated ;  sour,  rancid  eructation  after 
eating. 

ad  7. — Hard,  uneven  tumor  at  the  pj^lorus,  visible  gastric  rigidity. 
Pulse  54. 

Stomach  contents:  "Coffee-grounds,"  HCl  negative,  abundant  lactic- 
acid  bacilli.     Melena. 

ad  8. — Beginning:  November,  1902. 

Status  presens :  March  13,  1903. 
Duration:  About  4<  months(.'^). 
Epicrisis:  Longevity  of  parents.  This  is  a  statement  recurring  fre- 
quently in  the  previous  history  of  cancer  patients.  In  this  case  there  is 
a  clear  historj^  of  ulcer  dating  back  ten  A^ears  with  numerous  intervals 
free  from  symptoms  and  repeated  relapses.  It  is  one  of  those  forms 
of  ulcer  in  which  the  clement  of  pain  is  more  or  less  absent,  prone  to 

"See  R.  Sepc/eL  Uber  die  Mitheteiligung  der  vorderen  Bauchwand  beim  Magencar- 
cinom.     Miinchener  med.  Wochenschr.,   1898,  page  664. 


202  TUMORS    OF    THE    ABDOMINAL    VISCERA 

hematemesis  in  the  midst  of  good  health,  and  in  which,  pain  not  being 
present  to  act  as  a  deterrent,  traumatic  injuries  may  very  easily  come 
about  through  ingested  food. 

This  case  is  another  illustration  of  the  ominous  erroneous  diagnosis 
of  "gastric  catarrh."  The  imbibition  of  Karlsbad  water  in  this  case 
provokes  continued  "coffee-ground"  vomiting. 

Case  36. — S.  B.,  60  years,  M.     Forester. 

ad  1. — Father  and  mother  re<ached  the  age  of  70;  father  died  of 
pulmonary    tuberculosis. 

ad  2. — Always  frail,  which  exempted  him  from  military  service. 
Otherwise  healthy  up  until  1879.  In  November,  1902,  and  February, 
1903,  suffered  from  "gouty"  complaints  in  the  left,  later  also  in  the 
right   foot. 

ad  3. — No  infectious  diseases. 

ad  4. — In  1879,  he  suffered  from  loss  of  appetite,  disgust  for 
meat  and  severe  emaciation ;  at  that  time  twice  vomited  enormously  pro- 
fuse quantities  of  richly  brown-colored  mucoid  material.  Disease  passed 
over  painlessly.  Subsequently  could  tolerate  everything  very  well ;  in 
fact,  had  a  very  good  stomach  ;  "I  could  have  eaten  stones  and  lead." 
Bowels  also  were  regular. 

ad  6. — In  November,  1902,  patient  noticed  distention  of  the  gas- 
tric region,  had  feeling  of  pressure  after  intake  of  nourishment.  This 
lasted  until  February,  1903.  Then  there  set  in  eructations  with  the 
odor  of  decomposed  eggs  (SH2),  loud,  "like  the  whistle  of  a  locomotive." 
"Erection"  of  the  stomach,  severe  constipation.  Disinclination  toward 
meat,  desire  for  farinaceous  foods,  which  formerly  he  did  not  like.  On 
account  of  the  occurrence  of  severe  flatulence,  he  cannot  take  the  latter. 
No  pain. 

ad  7. — The  indistinct  tumor  can  be  felt,  corresponding  to  the  py- 
lorus. Distinct  gastric  peristalsis,  painless,  appearing  especially  on  mov- 
ing about.  Mild  intestinal  peristalsis  also  visible.  Yellowish  coloration 
of  the  face,  no  edemas,  severe  emaciation.  Since  three  weeks  ago  profuse 
vomiting  every  third  da}',  often  at  night. 

Stomach  contents:  "Coffee-grounds,"  abundance  of  lactic-acid  bacilli. 

ad  8. — Beginning:  November,  1902. 

Status  presens:  May  27,  1908. 
Operation :  June  -1,  1903. 
Autopsy:  June  16,  1903. 
Duration:  About  8  months. 

ad  9. — Operation  (Docent  Dr.  D.  Pupovnc)  :  A  carcinoma,  taking 
in  the  pylorus  and  lesser  curvature,  adherent  to  the  under  surface  of  the 
liver  and  the  head  of  the  pancreas. 

Autopsy  (Professor  Dr.  A.  Glion)  :  Ulcerating,  infiltrating  cancer  of 
the  pylorus.     Gastro-enterostomy  June  4. 

Epicrisis:  In  November,  1902,  therefore  synchronous  with  the  first 
symptoms  of  the  developing  cancer,  "gouty"  symptoms  are  said  to  have 
appeared  in  the  left  foot. 


CARCINOMA    OF    THE    STOMACH  203 

It  is  c'liiiic'.illv  certain  that  exogenous  irritants  take  ])art  in  the  causa- 
tion of  cancerous  proliferations.  The  assumption  lies  close  to  liand  also 
that  endogenous  irritants  exerted  through  their  chronic  effect  on  the 
body  secretions  by  metabolic  anomalies,  may  act  similarly  as  an  etiologi- 
cal factor. 

Here  also  is  the  case  of  a  "stomach  athlete."  "Stones  and  lead  I 
could  have  eaten."  Similar  expressions  are  frequently  heard  from  cancer 
patients. 

The  belching  of  gas  in  this  case  is  of  an  explosive  character  ("like 
the  whistle  of  a  locomotive"),  more  frequently  observed  in  gastric  neu- 
roses  (aerophagic,  etc.). 

The  odor  of  the  belched  gases  (SH2)  guards  against  confusion. 

Case  37.— B.  M.,  47  years,  M.     Contractor. 

ad   1. — Parents  lived  to  old  age;  8  brothers  and  sisters  healthy. 

ad  2. — Very  corpulent,  102  kg  before  being  taken  sick. 

ad  3. — No  infectious  diseases ;  no  lues. 

ad  4. — Foods  difficult  to  digest  always  well  borne;  preference  for 
very  sour  and  highly  seasoned  foods,  also  liked  hot  foods.  Bowels  always 
regular. 

ad  5. — Never  was  sick. 

ad  6. — At  Christmas,  1902,  still  well,  could  eat  and  drink  any- 
thing. Constipation  had  set  in  some  time  before  Christmas  (formerly 
quite  regular).  About  New  Year's,  1903,  the  appetite  diminished,  14< 
days  later  already  "coffee-ground"  vomiting  and  black  stools.  Pressure 
in  stomach,  especially  after  eating  meat,  and  that,  immediately  after 
eating.  The  patient  became  pale  and  rapidly  emaciated.  Early  in  May, 
1903,  Karlsbad  Miihlbrunn  and  Sprudel  salt  were  prescribed  for  one 
month.  The  condition  became  worse.  Frequent  eructation  with  very 
sour  taste.  Since  the  beginning  of  the  vomiting,  pains,  especially  under- 
neath the  right  costal  arch. 

May,  1903  (after  Karlsbad  cure)  :  Severe  pains  radiating  from  the 
epigastrium  upward  to  the  middle  of  the  sternum,  and  especially  to  the 
right  over  the  region  of  the  liver. 

June,  1903:  Pain,  especially  to  the  right,  in  the  epigastrium,  from 
there  extending  upward  over  the  lower  anterior  portions  of  the  thorax, 
where  there  is  an  internal  "feeling  of  heat,"  a  sort  of  "raging,"  particu- 
larly before  vomiting  and  after  eating.  Right  lateral  position  impos- 
sible during  attack  of  pain. 

ad  7. — Tumor-masses  in  the  region  of  the  liver  and  underneath  the 
border  of  the  liver.  "Peritoneal"  friction  in  the  epigastrium,  especially 
during  expiration.  Pale  yellow  coloration  of  the  face  (without  icterus) 
since  January,  1903.  No  edemas.  Frequent  profuse  vomiting  of  "cof- 
fee-ground" masses  without  HCl,  with  abundant  lactic-acid  bacilli. 

ad  8. — Beginning:  December,  1902. 

Status  presens :  June  6,  1903. 
Duration  :  About  G  months. 


204.  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Epicrisis:  Constipation,  where  formerly  the  bowels  were  regu- 
lar, seems  to  have  been  the  first  symptom  of  beginning  cancer  of  the 
stomach. 

The  subjective  symptoms,  such  as  "colics  of  pyloric  stenosis,"  come 
prominently  into  the  foreground. 

An  important  physical  sign,  the  determination  of  which  is  too  fre- 
quently forgotten  in  abdominal  diseases,  is  "peritoneal"  friction  in  the 
epigastrium. 

Case  38.— M.  F.,  56  years,  F. 

ad  2. — At  9  years  of  age  attacks  of  headache  on  right  side  with 
"cramps  of  the  jaw,"  particularly  when  excited;  improved  on  bromides. 
Otherwise  was  always  healthy. 

ad  3. — No  infectious  diseases. 

ad  6. — In  the  spring  of  1901,  beginning  of  stomach  coniplaiiils ; 
after  ingestion  of  food,  pressing  pains,  radiating  from  the  epigastrium 
toward  the  esophagus,  especially  if  moving  about  immediately  after  meals. 
Decrease  of  appetite ;  no  vomiting,  no  eructation. 

October,  1902:  Great  sensitiveness  to  pressure  in  the  abdomen  on  the 
left  side,  constipation,  could  eat  almost  nothing.  Operation  in  the  clinic 
of  Hofrat  Professor  Dr.  K.  Gussenhauer. 

March,  1903:  Must  vomit  everything.  In  October,  1902,  pricking 
pains  in  left  great  toe  (Autopsy:  Atheromatosis  of  the  anterior  tibial 
artery),  accompanied  by  feeling  of  cold.  June,  1903,  these  complaints 
are  so  bad  that  the  patient  cannot  sleep.  The  pain  extends  up  to  the 
ankle-joint.  The  pains  set  in  especially  after  moving.  The  left  foot  feels 
colder,  livid  discoloration.  Slight  relief  while  rubbing  the  painful  places 
with  the  hand. 

ad  7. — Extensive  tumor-mass  underneath  the  left  costal  arch. 
Lingual  nmcous  membrane  slightly  atrophic  at  the  lateral  borders.  Pale 
yellow  coloration  of  the  face  (without  icterus),  no  edemas. 

ad   8. — Beginning:  About  March,  1901. 
Status  presens:  flunc  9,  1903. 
Autopsy:  June  24',  1903. 
Duration :  About  2  years,  3  months. 

ad  9. — Autopsy  (Professor  Dr.  0.  Sfoerk)  :  Flat,  ulcerated  carci- 
noma, involving  the  entire  region  of  the  pylorus.  Severe  atheromatosis 
above  the  bifurcation  of  the  aorta ;  at  the  latter  place  thrombus  forma- 
tion. Atheroma  of  high  degree  of  both  crural  arteries;  the  left  ante- 
rior tibial  artery  especially  seems  to  be  greatly  affected  and  throm- 
bosed. 

Epicrisis:  Remarkable  are  the  great  atheromatous  changes  in  the  ab- 
dominal aorta  and  in  the  arteries  of  the  legs  discovered  at  autopsy ;  clin- 
ically, the  symptoms  of  an  impending  gangrene  of  the  toes  stand  promi- 
nently in  the  foreground.  It  is  conceivable  that  the  endogenous  injuries 
which  produced  the  severe  vascular  diseases  might  also  take  part  in  the 
causation  of  the  cancer  development. 


CARCINOMA    OF    THE    STOMACH  205 

Case  39. — F.  K.,  39  years,  M.    Dairyman. 

ad   1. — Fnther  died  at  50  of  pulmonarv  tuberculosis. 

ad  2. — Between  the  ages  of  12  and  15  had  one  "epileptic"  attack 
every  month. 

ad  3. — No  infectious  diseases  in  childhood.  At  18  had  malaria 
for  3  months  (lived  on  the  Thaya).  At  20  years  of  age  iiad  pneumonia 
for  6  weeks.  In  1902  had  erysipelas  for  3  months.  Two  years  ago  lues 
(treatment  by  mouth  and  by  injections). 

ad  4. — Always  had  a  very  good  stomach,  tolerating  also  fat,  bow- 
els regular.     Preference  for  sour  foods. 

ad  5. — Heavy  smoker  and  drinker. 

ad  6. — In  September,  1902,  beginning  of  gastric  complaints.  In 
the  morning  on  a  fasting  stomach  heartburn  and  sour  eructation,  stool 
was  formerly  regular,  now  at  times  constipated,  at  times  diarrhcic.  In 
February,  1903,  the  patient  started  vomiting,  in  the  beginning  only  after 
the  noonday  meal,  two  or  three  times  during  the  week,  later  on  also 
after  breakfast  and  after  the  evening  meal.  In  March,  1903,  cutting 
pains  in  the  umbilical  region,  radiating  from  there  horizontally  to  the 
right  and  left,  especially  on  a  fasting  stomach  in  the  morning  and  after 
vomiting  also  at  night.  Since  April,  1903,  pain  especially  when  turning 
about  to  the  right,  a  feeling  as  if  something  becomes  displaced  to  the 
right.  Right  lateral  position  impossible  during  an  attack  of  pain.  In 
June,  1903,  intolerance  for  milk  and  fat  foods.  No  disgust  for  meat. 
Appetite  not  bad. 

ad  7. — A  hard,  rough  tumor  as  big  as  an  apple  somewhat  to  the 
right  and  above  the  navel ;  gastric  peristalsis  visible.  Now.  and  then  also 
intestinal  peristalsis  above  Poupart's  ligament.  No  edemas.  Pulse  under 
60.  Vomiting  usually  ten  minutes  after  intake  of  food.  HCl  negative. 
Abundant  lactic-acid  bacilli. 

ad  8. — Beginning:  September,  1902. 
Operation:  June  27,  1903. 
Duration:  About  10  months. 

ad  9. — Finding  at  operation  (Docent  Dr.  D.  Pupovac)  :  Tumor 
(cancer)  of  the  pylorus,  about  the  size  of  a  child's  fist;  adhesion  of  the 
anterior  surface  of  the  stomach  to  the  transverse  colon.  Retroperitoneal 
gland  metastases  at  the  upper  border  of  the  pancreas  (gastro-enteros- 
tomy  retrocol). 

Epicrisis:  Disturbances  of  formerly  regular  bowel  evacuations  (con- 
stipation alternating  with  diarrhea)  count  also  in  this  case  among  the 
initial  manifestations. 

No  disgust  for  meat,  no  anorexia  (June,  1903!).  Very  definite  pain- 
ful position  of  the  right  side  corresponding  to  the  localization  at  the 
pylorus. 

Also  in  this  case  of  pathologically  increased  and  visible  gastric  peri- 
stalsis there  could  be  noticed  peristalsis  of  the  bowel. ^^ 


"  See  Jiiige  84. 


206  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  40.— J.  B.,  64  years,  M. 

ad  2. — In  December,  1902,  pains  in  the  right  shoulder-joint;  had 
to  stay  in  bed  for  14  days. 

ad  3. — No  infectious  diseases  in  childhood.  In  1893  had  "bloody 
dysentery"  for  8  days. 

ad  4. — No  gastro-intestinal  disturbances.  Bowels  always  regular; 
hemorrhoids  for  some  years. 

ad   5. — Always  was  healthy. 

ad  6. — In  December,  1902,  whilst  still  enjoying  good  appetite,  the 
bowels  began  to  be  tard}^  movements  obtainable  only  through  irrigation. 
Straining  at  stool  alreadj^  at  that  time  accompanied  by  pressing  pains 
in  the  epigastrium.  Soon  after  eructation,  feeling  of  distention,  disgust 
for  boiled  beef,  sensitive  to  strong  odors.  Condition  made  worse  b}-  cures 
in  Karlsbad  and  Luhatschowitz.  Since  the  end  of  June,  1903,  severe 
emaciation;  since  then  also  a  feeling  of  pressure  in  the  epigastrium  to- 
gether with  a  sensation  "as  if  wind  and  stool  must  come  through  the 
mouth."  Moist  compresses  cause  discharge  of  wind  and  afford  relief.  In 
right  lateral  position  increase  of  the  pressing  pains,  raising  of  the  lower 
abdominal  region  upward  brings  relief. 

ad  7. — A  transversely  running  sausage-shaped  resistance  in  the 
region  of  the  pylorus  palpable  now  and  then.  Abdomen  sunken.  Pale 
yellowish  coloration  of  the  face  (without  icterus).  Vomiting  only  of  late. 
Frequently  about  half  a  spittoonful  of  mucoid  glassy  fluid  without  odor 
or  taste  is  discharged  through  the  mouth. 

Stomach  contents:  HCl  negative;  sarcina>  and  rather  abundant  very 
long  lactic-acid  bacilli. 

ad  8. — Beginning:  About  December,  1902. 
Status  prescns:  Julv  27,  1903. 
Operation :  July  29*,  1903. 
Autopsy:  August  13,  1903. 
Duration:  About  7  months, 
ad  9. — Operation  (Clinic  Hofrat  Professor  Dr.  A'.  Gussenhauer)  : 
Very  large  carcinoma  at  the  pylorus,  adherent  to  the  liver.      No  ascites. 
Gastro-enterostomy  performed  with  difficulty. 

Autopsy  (Professor  Dr.  A.  Ghon) :  Infiltrating  carcinoma  of  the  py- 
lorus (scirrhus)  with  much  constriction.  Secondary  carcinoma  of  the 
serosa  in  the  region  of  the  diaphragm. 

Epicrisis:  Constipation  following  formerly  regular  bowel  movements 
as  an  initial  symptom ! 

Similar  to  some  cases  of  ulcer  the  presence  here  of  carcinoma  provokes 
pain  in  the  epigastrium  when  the  abdominal  wall  is  brought  into  action 
(straining  at  stool).     Right  "painful  position." 

The  vomiting  of  surprisingly  large  quantities  of  mucous  (odorless  and 
tasteless)  is  worthy  of  note. 

Case  41. — B.  J.,  46  years,  M.    Day  laborer. 

ad  1. —  Parents  died  of  pulmonary'  tuberculosis.  Five  brothers  and 
sisters  are  alive  and  well. 


CARCINOMA    OF    THE    STOMACH  207 

ad   3. — No  infectious  diseases. 

ad   5.— During  ciiildhood,  and  also  later,  always  healthy;  moderate 
drinker,  heavy  smoker;  tiie  present  disease  is  his  first. 

ad  6. — He  says  that  in  the  autumn  of  1901  he  spoiled  his  stomach, 
and  since  then  on  and  off  has  indefinite  diffuse  pains  in  the  rl'gion  of  the 
stomach,  vomited  several  times.  Otherwise  felt  quite  well.  Only  in  March, 
1902,  the  appetite  became  worse.  The  patient  began  looking  pale.  Con- 
stant uncomfortable  feeling  in  the  epigastrium,  witiiout  being  particularly 
influenced  by  ingestion  of  food.  In  the  beginning  of  the  disease  moderate 
eructation,  no  heartburn.  Nausea  without  vomiting.  The  patient  worked 
until  Christmas,  1902,  at  which  time  he  noticed  a  swelling  of  the  feet, 
about  the  ankles.  In  the  summer  of  1903  the  stools  became  diarrheic, 
since  then  four  to  five  bowel  movements  daily.  Since  June,  1903,  tiie  legs 
are  edematous ;  the  patient  has  lost  but  little  in  weight.  No  actual  pains, 
ad  7. — Tongue  coated,  nmcous  membrane  slightly  atrophic.  A 
tumor-mass,  the  size  of  an  apple,  on  the  right  above  the  navel ;  over  it 
tympany,  as  also  over  the  region  of  the  liver.  Very  severe,  soft,  pale 
edema  in  the  lower  extremities,  on  the  back  and  especially  in  the  scrotum ; 
also  edema  of  the  belly-walls. 

Stomach  contents:  Abundant  bacterial  flora,  consisting  of  bacteria 
coli,  lactic-acid  bacilli  and  sarcinjB  (sporadic).     HCl  negative, 
ad  8. — Beginning:  Autumn,  1901. 

Status  presens :  August  4,  1903. 
Duration:  About  2  years. 
Epicrisis:  So  frequently  the  case,  absence  of  infectious  diseases  in  the 
previous  history !     This  case  belongs  to  the  "anemic-hydropic"  type  of 
gastric  cancer. 

We  are  dealing  with  a  soft  ulcerating  carcinoma  at  the  pylorus  with- 
out much  constriction.  Therefore  the  element  of  pain  is  almost  absent 
and  the  subjective  symptoms  on  the  part  of  the  stomach,  despite  the  large 
size  of  the  tumor,  are  slight. 

Colon  bacilli,  in  large  quantity,  is  a  frequent  finding  in  just  these  soft, 
severely  ulcerating  forms  of  gastric  cancer;  no  doubt  it  takes  part  in  the 
formation  of  lactic  acid. 

Case  42. — J.  W.,  35  years,  M.    Farmer. 

ad  1. — Father  died  at  60  years  of  age  from  stomach  and  liver  dis- 
ease (Ca.'*).     Mother,  brothers  and  sisters  are  healthy. 

ad  2. — At  from  15  to  16  years  of  age  often  had  nose-bleed  (dura- 
tion up  to  one  day)  especially  in  summer;  after  marriage  this  is  said  to 
have  stopped. 

ad  3. — When  12  years  old  had  malaria  from  May  to  October;  sub- 
sequently always  well. 

ad  4. — Stomach  always  very  good,  could  tolerate  everything;  liked 
to  eat  hot  foods. 

ad  5. — Heavy  drinker  and  smoker. 

ad  6. — In  March,  1903,  appearance  of  pains  in  the  epigastrium, 
partly  at  night,  partly  during  the  day.     Epigastrium  became  sensitive 


208  TUMORS    OF    THE    ABDOMINAL    VISCERA 

to  pressure;  constipation.  Three  weeks  after  appearance  of  pain  the 
appetite  became  less.  Meat  was  no  longer  tolerated,  only  milk  and  soup. 
Bowels  often  did  not  move  for  a  week.  Until  August,  1903,  no  vomiting, 
often  sour,  bitter,  ill-smelling  eructation.  Bitter  taste  in  the  mouth. 
Now  and  then  slight  bulging  in  the  epigastrium  accompanied  by  bor- 
borygmi.  In  the  beginning  the  pains  were  somewhat  assuaged  after 
drinking  coffee  or  sour  wine.  Later  on  were  continuous  night  and  day. 
Increase  of  pains,  especially  in  right  lateral  position. 

ad  7. — No  distinct  tumor  palpable.  Frequent  squirting  sounds  in 
the  pyloric  region,  pyloinis  not  particularly  sensitive  to  pressure.  No 
edemas.  Severe  anemia:  erythrocytes  1.2  millions,  Hgb.  207c,  leucocytes 
6,100,  pulse  10-1,  venous  hums.  "Coffee-ground"  vomiting,  abundant 
sarcin.T  and  yeast.     HCl  negative, 

ad  8. — Beginning:  March,  1903. 

Status  presens:  August  8,  1903. 
Operation:  August  14-,  1903. 
Duration:  About  6  months, 
ad  9. — Operation    (Docent   Dr.   D.  Pupovac)  :  Pyloric  carcinoma 
fixed  to  the  pancreas.     Glands  affected. 

Epicrisis:    Gastralgias    mark    the    clinical    beginning   of   the    disease, 
anorexia  following  afterward.     Constipation  (absence  of  bowel  movements 
for  a  week)  in  this  case  counts  among  the  early  symptoms. 
Right-sided  "painful  position." 

The  use  of  coffee  or  sour  wine  affords  relief  from  pain  in  the  begin- 
ning, probably  by  promoting  evacuation  of  the  stomach. 

The   subsequently  existing  continuous  pains,  uninfluenced  by   intake 
of  food,  might  be  due  to  encroachment  of  the  tumor  on  the  pancreas. 

Case  43. — F.  D.,  72  years,  M.     Coachman. 

ad   1.^ — Several  children  died  of  tuberculosis. 

ad  3. — No  infectious  diseases. 

ad  5. — Never  was  sick — except  for  a  "cold,"  after  which  severe 
catarrh,  and  since  then  frequent  coughing.  Heavy  drinker.  Pain  over 
the  lower  portion  of  tiie  sternum  and  in  the  epigastrium  on  walking. 
Anorexia. 

ad  7. — Numerous  hard  glands  in  the  right  supraclavicular  fossa. 
Left  pulmonary  apex  slightly  dull,  with  few,  moist  rales.  Left  brachial 
plexus  very  sensitive  to  pressure.     Cachectic  color  of  the  face;  no  edemas. 

ad  9. — Autopsy,  November  9,  1903  (Hofrat  Professor  Dr.  A. 
Weicliselhaum)  :  Nodular  and  infiltrating  carcinoma  of  the  stomach  with 
metastases  in  the  lesser  and  greater  curvatures,  in  the  large  omentum,  in 
the  mesenteric  and  retroperitoneal  as  well  as  in  the  right  bronchial  and 
supraclavicular  lymph-glands.  ^Metastases  in  the  pleura  on  both  sides. 
Small  partial  aneur^^sm  of  the  heart  with  atheroma  of  the  coronary 
arteries. 

Epicrisis:    In    this    case   during   life   the   possibility    of   a   pulmonary 
carcinoma  was  thought  of.     ^Metastasis  in  the  right  supraclavicular  glands 


CARCINOMA    OF    THE    STOMACH  209 

is  very  unusual  in  connection  with  gastric  cancer.     In  this  case  it  may 
by  explained  by  hii  abnormal  right-sided  course  of  the  thoracic  duct.^' 

Besides  right-sided  involvement  of  the  glands  there  was  also  involve- 
ment of  the  pleura.  Apical  dulness,  due  to  fibrous  tuberculosis,  is  not 
a  rare  finding  in  gastric  cancer,  and  this  finding  may  easily  be  mislead- 
ing, the  more  so,  as  gastric  disturbances  often  accompany  tuberculosis. 

Case  44.— 0.  A.,  62  years,  F. 

ad   1. — Parents  died  in  advanced  age. 

ad  3. — No  infectious  diseases. 

ad  4. — Never  had   stomach  complaints. 

ad  5. — Had  12  children,  of  whom  3  only  are  living.  She  herself 
was  never  sick. 

ad  6. — In  January,  1903,  cramp-like  pains  started  underneath  the 
right  costal  arch,  radiating  into  the  right  back.  Appetite  became  worse. 
In  August,  1903,  had  to  vomit  several  times.  Very  painful  attacks  in 
the  beginning,  often  5  to  6  times  a  day,  lasting  2  to  3  hours.  In  the 
beginning  the  attacks  came  on  daily,  since  2  months  ago  has  no  more 
pains.  For  the  past  5  or  6  months  rather  pressing  pains  in  region  of 
the  tumor.     There  might  be  an  appetite,  but  the  patient  is  afraid  to  eat. 

ad  7. — Tumor  the  size  of  an  apple,  in  the  region  of  the  pylorus 
(noticed  since  August,  1903).  The  tumor  shifts  spontaneously,  now 
somewhat  to  the  right  and  then  somewhat  to  the  left,  with  left  lateral 
position,  becomes  displaced  to  the  left.  On  making  pressure  over  the 
tumor  the  gastric  contents  escape  from  above.  Since  two  months  ago 
frequent   vomiting;  bowels   constipated. 

Stomach  contents:  "Cofifee-grounds,"  HCl  negative,  abundant  lactic- 
acid  bacilli. 

ad  8. — Beginning:  January,  1902. 

Status  presens :  December  30,  1903. 
Duration :  About  1  year. 
Epicrisis:  The  previous  history,  as  is  so  frequently  the  case,  yields  the 
trio:  "Never  any  infectious  disease;  never  any  disease  at  all;  stomach 
always  in  perfect  condition !" 

A  "colic  of  pyloric  stenosis"  (type  of  "pseudo-gall-stone  colic") 
introduces  the  disease.  Then  there  follows  the  deceptive  remission  of 
the  pain  phenomena.  In  some  cases  this  is  explained  by  the  freeing  of 
the  pyloric  passage  as  a  result  of  ulceration ;  the  cessation  of  HCl  secre- 
tion also  enters  into  consideration,  the  development  of  the  cancer  having 
the  same  effect  as  continued  large  doses  of  soda  bicarbonate ;  finally  the 
preservation  of  the  stomach,  involuntarily  effected  by  the  increasing 
anorexia,  must  also  be  taken  into  account. 

Spontaneous  wandering  of  tumor-masses  in  the  epigastrium  are,  in  and 
of  themselves,  a  fairly  certain  indication  that  they  belong  to  the  stomach, 
and  their  diagnosis  may  be  very  important  in  order  to  differentiate  them 
from  firmly  fixed  tumors  of  the  liver. 

^^Hosch,  Grenzg.  der  Med.  und  Chir.,  Vol.   18,  page  489. 


210  TUMORS    OF    THE    ABDOIMINAT.    VISCERA 

The  wandering  is  explained  by  the  changed  condition  of  distention 
of  the  stomach  and  perhaps  also  of  the  transverse  colon. 

The  patients  themselves  often  call  attention  to  the  fact  that  at  dif- 
ferent times  they  feel  the  tumor  in  different  places. 

Also  the  fact  that  pressure  upon  the  tumor  leads  to  immediate  regurgi- 
tation upward,  makes  the  diagnosis  of  the  swelling  certain. 

Case  45.— B.  K.,  65  years,  F. 

ad  2. — Between  the  ages  of  17  and  2-i  there  were  present  nmltiple 
small  ulcers  on  both  lower  extremities,  which  issued  from  small  infiltra- 
tions. Had  six  children,  abortion  in  the  third  month  only  with  the 
seventh. 

ad  3. — No  infectious  diseases. 

ad  4. — Stomach  always  very  good ;  only  eggs  were  badly  borne. 

ad  6. — Since  1902,  constipation,  appetite  became  irregular.  Since 
November,  1903,  now  and  then  nausea  and  inclination  to  vomit;  on  and 
off  eructation  having  the  odor  of  SH2 ;  complete  anorexia,  continued  con- 
stipation; very  often  biliary  vomiting.  Pain  in  the  belly  on  both  sides; 
increasing  after  ingestion  of  food,  improvement  after  bowel  movements. 
Right  lateral  position  better  tolerated. 

ad  7. — Tongue  slightly  coated.  Belly  distended,  sensitive  to 
pressure ;  ascites.  Hard,  uneven  tumor-masses  in  the  epigastrium. 
Tumors  varying  from  the  size  of  a  hazelnut  to  a  walnut  can  be  felt 
through  the  posterior  vaginal  wall.  Slight  retromalleolar  edema.  Reflow 
in  gastric  lavage  very  bloody.  Never  any  "coffee-ground"  vomiting. 
Urine:  Indican  test  (Obermeyer)   strongly  positive. 

ad  8. — Beginning:  1902. 

Status  prcsens :  January  25  and  March  1,  1904. 
Autopsy:  March  19,  1904. 

ad  9. — Autopsy  (Decent  Dr.  K.  Landsteiner)  :  Crater-like  car- 
cinoma immediately  below  the  cardia  with  scirrhus  metastases  in  the 
peritoneum  and  omentum ;  numerous  liver  metastases. 

Epicrisis:  One  of  those  cases  of  gastric  cancer  in  which  there  is  also 
present  a  positive  gynecological  finding  (tumors  palpable  through  the 
posterior  vaginal  wall!).  Mistakes  may  be  made,  especially  in  those 
cases  where  the  metastases  take  place  in  the  ovaries. 

As  the  neoplasm  did  not,  as  is  usual,  lie  in  the  neighborhood  of  the 
pylorus,  but  just  below  the  cardia,  vomiting  of  bile  resulted,  which  is 
not  commonly  observed  in  pyloric  constrictions.  Right  lateral  decubitus 
is  even  better  tolerated  than  left. 

Case  46. — L.  G.,  42  years,  M.     Coachman. 

ad   1. — No  hereditary  taint. 

ad  3. — Varicella  at  7  years  of  age;  typhoid  at  23  (8  weeks). 

ad  4. — Never  had  gastro-intestinal  disturbances. 

ad  6. — About  the  middle  of  November,  1903,  a  feeling  of  pressure 
came  on  in  the  epigastrium  after  every  meal,  especially  after  eating  solid 


CARCINOMA    OF    THE    STOMACH  211 

foods,  disappearing  three-fourths  of  an  liour  afterward.  Intolerance  for 
boiled  beef,  sour  wine  and  beer.  No  pain  on  a  fasting  stomach.  Pain  in 
the  epigastrium  immediately  after  ingestion  of  food  ;  duration,  one-half 
hour. 

Accompanying  manifestation:  belching  of  air  with  relief.  No  vomit- 
ing, no  nausea.  Inci-ease  of  pain  by  being  shaken  up  while  riding  in  a 
wagon  and  when  in  left  lateral  position.  Such  painful  conditions  until 
January,  1904.  From  then  on  continuous  pains  in  the  left  side  of  the 
epigastrium  not  related  to  intake  of  nutrition.  Turning  from  the  back 
to  the  side  is  painful.  Changing  over  to  the  left  side  is  almost  impos- 
sible.    Appetite  good  until  January,  1904. 

ad  7. — Liver  somewhat  enlarged,  tough,  sensitive  to  pressure  upon 
percussion  over  the  left  lobe;  a  distinct  systolic  murmur  audible  over  the 
liver.     Mild  subicteric  discoloration. 

Urine:  In  the  beginning  urobilinogen  only,  later  bilirubin  also  demon- 
strable. 

Blood:  Leucocytes,  19,000.     Hgb.  75%. 
ad  8. — Beginning:  November,  1903. 

Status. presens  :  February  24,  1904. 
Autopsy:  March  5,  1904. 
Duration:   3^   months    (?). 
ad  9. — Autopsy    (Docent  Dr.  J.   Bartel)  :   Scirrhus   carcinoma   of 
the  lesser  curvature,  central  ulceration,  diffuse  and  uniform  carcinomatous 
infiltration  of  the  liver. 

Epicrisis:  The  initial  attacks  of  pain,  elicited  b}'  intake  of  food,  are 
of  gastric  origin  and  are  connected  with  the  development  of  cancer  in 
the  stomach  itself. 

The  pains  appearing  toward  the  end  of  January,  not  affected  by  in- 
take of  food,  are  of  hepatic  origin  and  are  probably  referable  to  an 
accompanying  perihepatitis  and  capsular  tension  resulting  from  car- 
cinomatous infiltration  of  the  liver. 

In  such  cases  the  patients  are  frequently  compelled  to  assume  the 
dorsal  decubitus,  as  the  lateral  positions,  especially  turning  over  to  the 
left  side,  cause  most  violent  pain  due  to  the  pulling  of  the  liver,  which 
has  increased  in  weight,  on  inflammatory  adhesions,  suspensory  ligaments, 
etc.  The  process  of  infiltration  in  the  liver  also  reveals  itself  on  auscul- 
tation by  a  systolic  murmur,  moreover  by  abundant  elimination  of  uro- 
bilinogen in  the  urine,  later  followed  by  bilirubinuria. 

Case  47.— V.  C,  63  years,  M. 

ad  1. — Mother  died  at  75  of  old  age. 

ad  3.^ — At  18  had  typhoid  for  6  weeks;  at  28,  pneumonia  for  2 
weeks. 

ad  5. — Since  2  years  ago  weakness  in  legs,  for  the  past  3  years 
paresthesias  in  the  fingers  (Autopsy:  Syringomyelia).     Heavy  smoker. 

ad  6. — Since  ]\Iarch  21,  1904,  feeling  of  pressure  in  the  epigastrium 
after  eating.  Aery  slight  subjective  complaints  during  the  entire  course; 
the  patient  eats  meat  up  to  the  last. 


212  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  7. — Hard,  cylindrical  tumor,  transversely  situated  in  the  epi- 
gastrium ;  over  it  "snow  treading"  sound  is  palpable  and  friction  can  be 
heard.     Now  and  then  eructation  of  "cofFee-ground"  masses  containing 
abundant  lactic-acid  bacilli.     Stubborn  constipation.     HC1.{  absent. 
Urine:  Usually  over  2,000  cm  a  day. 

Blood:  Erythrocytes,  5,100,000;  hemoglobin,  60%  ;  leucocytes,  4,200. 
Edema    of    the    lower    extremities.      Right    calf    hard,    hot,    painful. 
(Autopsy:  Thrombosis  of  the  right  crural  vein.) 
ad  8.- — Beginning:  end  of  March,  1904". 
Status  presens:  August  30,  1904. 
Autopsy:  December  22,  1904, 
Duration:  about  9  months, 
ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Ulcerating  carcinoma 
of  the   pylorus    and   stenosis    of   same,   together   with    adhesions    to    the 
under  surface  of  the  liver.     Secondary  carcinoma  of  the  regional  lymph- 
glands.     Dilatation  of  the  stomach.     Induration  of  left  pulmonary  apex 
from  tuberculosis,  left-sided  walled-off  cheesj'^  pleuritis.     Multiple  tuber- 
cular caries   of  the   ribs.      Syringomyelia   throughout    the   entire   spinal 
cord  with  distinct  formation  of  cavities  in  the  gray  substance  of  the  cer- 
vical and  dorsal  portions  of  the  cord. 

Epicrisis:  The  subjective  symptoms  of  the  patient,  who  at  the  same 
time  was  suffering  from  syringomyelia,  were  extremely  mild. 

When  there  is  suspicion  of  carcinoma  of  the  stomach  attention  should 
always  be  paid  to  "peritoneal  friction"  showing  itself  on  palpation  as 
"snow  squeaking."  Especially  with  an  indistinctly  palpable  tumor  it  is  a 
very  significant  diagnostic  phenomenon. 

Case  48.— G.  A.,  38  years,  M. 

iid   1. — Both  parents  living  and  well. 

ad  3. — Varicella  at  6  years  of  age ;  otherwise  always  healthy. 

ad  4. — Stomach  was  always  very  good;  preference  for  strongly 
sour  foods,  which  also  now  are  well  tolerated. 

ad  6. — In  October,  1902,  the  appetite  diminished  with  respect  to 
all  foods.  No  disgust  for  meat ;  a  little  later,  constipation  set  in.  Since 
July,  1903,  a  feeling  of  distention  after  eating  and  sour  eructation. 
Pain  14  to  1  hour  after  intake  of  nutrition ;  in  left  lateral  position  eructa- 
tion affording  relief.  Feeling  of  pressure,  particularly  after  meat.  At- 
tacks of  pain  often  at  midnight.  Intolerance  for  meat  and  flour  foods 
prepared  with  yeast.     Among  others  beer,  wine  and  fat  are  tolerated. 

ad  7. — Tumor  of  the  pylorus  palpable,  especially  with  left  lateral 
position,  of  varying  consistence;  distinct  gastric  peristalsis. 

Stomach  contents:  HCl  demonstrable  on  a  fasting  stomach,  abundant 
sarcinfe.     HCl  negative  after  lavage  and  test-breakfast. 

ad  8. — Beginning:  October,  1902. 

Status  presens:  April  14,  1904. 
Operation:  April  22,  1904. 
Duration:  About  ll/o  years. 

ad  9. — Operation:   Gastric   carcinoma   with   metastases. 


C'ARCIXOMA    OF    THE    STOMACH  213 

Epicrisis:  The  cliJinf^ing  coiisistenci'  of  i\\v  pyloi-ic  tumor  ;is  noted  hy 
the  palpating-  finf)vrs  is  accounted  for  by  the  chan<re  in  contraction  atul 
relaxation  of  the  pyloric  musculature. 

Such  findings  by  no  means  justify  us  in  assuminf^  a  j)urely  spastic- 
functionjil  natui-e  of  the  disi'ase. 

HCl  is  found  in  the  sta<rnating  stomach  contents,  evidently  resulting 
from  former  strong  irritants  (products  of  decomposition  of  ingested 
food?).  After  emptying  and  lavage  of  the  stomach  the  mild  irritation 
produced  by  the  test-breakfast  is  not  sufficient  to  elicit  HCl  secretion. 

Such  behavior  is  not  seldom  met  with  in  cancer  of  the  stomach. 

Case  49.— F.  D.,  41  years,  M.    Worker  in  Gold. 

ad  1. — Mother  died  of  tuberculosis,  brothers  and  sisters  of  chil- 
dren's diseases. 

ad  3. — Measles  in  childhood,  otherwise  always  healthy, 
•xd  4,, — Always  had  a  good  stomach;  was  in  the  habit  of  eating  hot 
foods  and  rapidly.     Severe  constipation  since  childhood. 

ad  5. — Has  to  stoop  while  seated  at  his  work,  in  pulling  wire  it 
frequently  happened  that  the  instrument  slipped  from  the  hand  and  hit 
against  the  epigastrium. 

ad  6. — Stomach  trouble  since  August,  1903.  After  eating  "gou- 
lash," pressure  in  the  stomach  and  nausea,  appearing  often  1  to  ll/^>  hours 
after  eating.  Sour  eructations,  now  and  then  having  the  odor  of  "rotton 
eggs."  Since  the  end  of  February,  190-1,  vomiting  soon  after  meals.  A 
feeline-  as  if  the  stomach  were  "too  narrow."  After  ingestion  of  food 
the  patient  cannot  lie  on  his  right  side  because  it  excites  nausea.  iSo 
pain,  only  feeling  of  pressure  in  the  epigastrium. 

ad  7.- — Hard,  uneven  tumor  at  the  lesser  curvature.     Stomach  in 
the  left  half  of  the  epigastrium  bulging  like  an  air-cushion.     Pulse  54. 
"Coffee-ground"  vomiting  containing  abundant  lactic-acid  bacilli. 
Urine:  Strong  indican  reaction  {Ohermeyer). 
ad  8. — Beginning:  August,  1903. 

Status  presens:  April  20,  1904. 
Operation:  April  26,  1904. 
Autopsy:  April  27,  1904. 
Duration :  About  8  months, 
ad  9. — Operation:  Carcinoma  of  the  pylorus  encroaching  on  the 
lesser   curvature,   stomach    enormously   hypertrophied,   only   slightly   di- 
lated, firmly  fixed  posteriorly. 

Autopsy:  Carcinoma  on  the  basis  of  a  gastric  ulcer. 
Epicrisis:  One  of  those  not  rare  cases  in  which  the  anatomical  find- 
ing speaks  for  a  preceding  ulcer,  whilst  clinically  there  are  no  grounds 
for  assuming  such  to  be  the  case. 

With  reference  to  the  "irritation  theory"  it  would  have  to  be  borne 
in  mind  that  the  patient  was  in  the  habit  of  eating  things  rapidly  and 
when  they  were  hot.  Also  he  had  to  stoop  a  great  deal  while  sitting  at 
his  work,  the  epigastrium  being  at  the  same  time  exposed  to  manifold 
traumas. 


2U  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Right  lateral  position  is  badly  tolerated,  not  because  it  elicits  pain 
but  because  it  excites  nausea  (carcinoma  at  the  pylorus!). 

Case  50. — F.  W.,  32  years,  M.     Coachman. 

ad   1. — Mother  died  of  some  pulmonary  disease. 

ad  3. — Varicella  at  6  years  of  age;  no  lues. 

ad  4. — Always  had  a  good  stomach ;  preference  for  sour  and  spicy 
foods. 

ad   5. — Moderate  drinker  and  smoker. 

ad  6. — Toward  the  end  of  May,  1904,  feeling  of  pressure  after  eat- 
in  "•  boiled  beef.  Frequent  stabbing  on  both  sides  underneath  the  costal 
arches  accompanied  by  a  feeling  of  distention  in  the  epigastrium;  later 
on  vomiting,  two  hours  after  meals.  Half  an  hour  after  ingestion  of 
food  pressure  and  contracting  pains  in  the  stomach  which  lasted  until 
vomiting  occurred.  In  riglit  lateral  position  there  is  a  feeling  as  if  somc- 
tliing  fell  over  to  the  right  side,  at  the  same  time  there  is  nausea. 

ad  7. — No  distinct  tumor  can  be  felt.  Visible  gastric  peristalsis 
without  actual  pain.     Pulse  48. 

Stomach  contents:  HCl  negative;  abundant  lactic-acid  bacilli. 

ad  8. — Beginning:  End   of  May,   1904. 

Status  presens:  August  30,  1904. 
Operation:    September    3,    1904. 
Duration :  3  months. 

ad  9.^ — Operation  (Docent  Dr.  A.  Exner)  :  Constriction  of  the 
pylorus  by  a  sjiarply  circumscrii)ed  carcinoma.  Glands  enlarged  both 
at  tlie  lesser  and  greater  curvature.  Resection  of  the  pylorus  and  gastro- 
enterostomy. 

Epirrisis:  The  intolerance  of  the  carcinomatously  diseased  stomach  is 
frequently  first  exhibited  toward  "boiled  beef,"  the  use  of  same,  so 
prevalent  in  A'ienna,  ividently  taxes  tlie  digestive  energy  of  the  stomach 
very  much. 

Here,  also,  there  exists  a  right-sided  "vomiting  position."  Brady- 
cardia is  a  peculiarity  of  the  ratlier  fibrous  carcinomas  constricting  the 
pylorus,  in  connection  with  which  there  are  losses  of  large  amounts  of 
fluid  as  a  result  of  copious  vomiting,  and  frequently  there  occurs  a  sort 
of  mummification  of  the  organism.  The  heart  in  these  cases  is  small 
and  atrophic. 

Case  51.— P.  M.,  30  years,  W. 

ad   1. — No  tuberculosis  In  the  family. 

ad  2. — Tubercular  habitus. 

ad  3. — No  infectious  diseases ;  was  always  healthy. 

ad  4. — Since  16  years  of  age  repeated  occurrence  of  gastric  trouble, 
especially  after  sweet  flour  foods  producing  flatulence,  mostl}'  I/4  to  l/o 
hour  after  eating,  accompanied  by  moderate  feeling  of  pressure  and  heart- 
burn. 

ad  6. — About  the  middle  of  August,  1903,  slight  pains  began 
below  the  xiphoid  process,  especially  upon  making  pressure  and  fasten- 


CARCINOMA    OF    THE    STOMACH  215 

ing  the  skirts;  pain  also  underneath  both  costal  arches,  lb  is  said  that 
puhnonary  catarrh  was  diagnosed  at  that  time.  Two  weeks  hiter,  again 
stabbing  pains  below  the  xiphoid  process,  radiating  into  both  sides  under 
the  costal  arches,  into  the  back  and  flanks.  Five  to  ten  minutes  after 
eating  feeling  of  pressure  in  stomach,  nausea  and  "perturbation"  in  the 
entire  abdomen.  Large  quantities  of  fluid  are  particularly  badly  tol- 
erated. Now  and  then  eructation  of  sour  fluid  or  gases  (having  the  odor 
of  "rotten  eggs").  Vomiting  of  tenacious,  white  mucous,  which  affords 
relief.  In  the  summer  of  1904;  the  vomiting  subsided.  She  could  tolerate 
only  milk  and  eggs,  all  other  food  being  vomited.  In  the  beginning  of 
September,  19()-t,  the  abdomen  gradually  enlarged,  during  the  last  8  days 
spontaneous  diarrheas.  Recently  swelling  of  the  lower  extremities.  Sen- 
sitiveness to  pressure  in  the  epigastrium ;  appetite  would  be  good,  but  the 
patient  is  afraid  to  eat. 

ad  7. — Ascites.  Epigastrium  filled  with  hard,  gland-like  tumors, 
which  rise  with  pulsation  and  yield  a  tympanitic  sound;  even  on  slightly 
pressing  the  stethoscope  in  the  epigastrium  it  is  possible  to  elicit  a  sys- 
tolic murmur.  Slight  edema  in  the  lower  extremities.  Right-sided  pleural 
effusion.  Venous  hums.  The  vomited  stomach  contents  contain  abun- 
dant, ver}'  long  lactic-acid  bacilli.  The  same  bacteriological  finding  in 
the  feces,  which  latter  also  contains  numerous  pus-cells,  some  of  them 
eosinophiles. 

Urine:  Very  strong  diazo  reaction,  which  disappears  synchronously 
with  the  occurrence  of  purulent  peritonitis,  7  days  prior  to  death. 

Blood:  Leucocytes,  13,000. 

ad  8. — Beginning:  About  August  15,  1903. 
Status  presens:  September  14,  1904. 
Autopsy:  October  14,  1904. 
Duration :  1  year,  2  months, 
ad  9. — Autops}^  (Docent  Dr.  J.  Bartel) :  Enormous  medullary  ul- 
cerating carcinoma  of  the  pars  pylorica  of  the  stomach  and  the  lesser 
curvature  with  perforation  and  diffuse  peritonitis.    jNIetastases  in  the  peri- 
portal  lymph-glands    and   infiltration    of   the   pancreas   with    carcinoma. 
Struma  cystica.     Pylorus  not  much  constricted. 

Epicrisis:  This  patient  was  referred  to  the  clinic  with  the  diagnosis 
"tuberculosis  of  the  peritoneum."  This  is  probably  the  most  frequent 
erroneous  diagnosis  in  cases  where  gastric  cancer  attacks  vouthful  in- 
dividuals and  is  accompanied  by  ascites. 

In  this  30-year-old  patient  there  w^as,  in  addition,  a  very  intense  diazo 
reaction,  which  is  ver}^  rarely  met  with  in  gastric  cancer,  but  almost  reg- 
ularly observed  in  tuberculosis  of  the  peritoneum. 

The  result  of  the  feces  examination  was  the  first  reason  for  changing 
the  diagnosis :  lactic-acid  bacilli !  Only  during  the  subsequent  course  did 
vomiting  occur,  yielding  identical  bacteriological  findings. 

Case  52.— H.  J.,  51  years,  M. 

ad  3. — No  I.  D.  C.  Typhoid  at  9  years  (duration,  6  weeks).  In 
1900,  left-sided  pneumonia. 


216  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  4<.—T- Always  had  a  good  appetite. 

ad  6. — In  the  beginning  of  July,  190-4,  frequent  heartburn  after 
eating  bread;  appetite  good  at  the  start.  In  August,  1904,  beginning  of 
pain  in  the  stomach.  Since  August,  1904,  continuous  pressing,  now  and 
then  cramp-like  pains  in  the  region  of  the  stomach,  sometimes  brought 
about  by  movements,  such  as  stooping.  Feeling  of  gastric  pressure,  es- 
pecially after  eating  meat.  Appetite  became  bad.  Pain,  especially  2  to 
3  hours  after  eating.     Sour  eructation  in  horizontal  position. 

September,  1904:  Copious  vomiting  of  strongly  sour  and  strongly 
mucoid  masses.  "Rolling"  in  the  region  of  the  stomach  and  visible  gas- 
tric peristalsis. 

ad  7. — No  distinct  tumor.  Epigastrium  little  sensitive, ,  loud 
splashing,  visible  gastric  peristalsis.  Small  hernia  in  the  linea  alba,  little 
painful.  Yellowish  pale  face  coloration.  Sarcinae  in  stools  and  stomach 
contents.  Food  rests  after  withdrawal  of  contents  from  fasting  stomach 
show  157o  and  after  test-breakfast  1%  HCl. 
ad  8.^ — Beginning:  June,  1904. 

Status  presens :  October  3,  1904. 
Operation:  October  21,  1904. 
Duration :  41/^  months, 
ad  9. — Operation  (Docent  Dr.  A.  Exner)  :  Carcinoma  at  the  py- 
lorus (hard  tumor,  the  size  of  a  nut),  encroaching  on  the  pancreas. 

Epicrisis:  Heartburn,  especially  after  eating  bread,  in  this  case  ap- 
pears as  an  early  symptom,  and  is  present  also  during  the  further  course 
(favored  by  horizontal  position). 

Hernias  in  the  linea  all)a  must  be  accepted  with  greatest  resei've  only 
as  the  cause  of  existing  gastric  disturbances ;  they  are  not  rare,  accom- 
panying manifestations  in  cases  of  gastric  cancer. 

As  repeatedly  emphasized,  the  appearance  of  symptoms  of  pyloric 
constrictions  (residues  from  the  previous  day,  sarcina',  visible  peristal- 
sis, colic  of  pyloric  stenosis)  with  stomach  complaints  of  only  several 
months'  duration,  is  always  highly  suspicious  of  malignancy. 

As  in  Case  48,  so  also  here,  the  stomach  contents  withdrawn  in  a  fast- 
ing condition  show  a  greater  HCl  content  than  those  obtained  after  a  test- 
breakfast  (with  previous  lavage). 

Case  53.— M.  J.,  57  years,  M. 

ad   1.- — Father  living  and  well. 

ad  3. — Scarlatina  at  10  j^ears  of  age  (at  19  had  general  edema 
for  17  weeks). 

1901 :  Chills  with  bloody  expectoration,  same  in  1903. 

ad  4. — Vomiting  now  and  then,  simultaneous  with  occurrence  of 
headache.     Bowels  always  regular. 

ad  6. — May,  1904 :  Loss  of  appetite,  disgust  for  meat ;  could  only 
take  liquid  food. 

August,  1904:  Frequent  heartburn,  severe  vomiting  after  every  meal. 
Bowels  irregular,  mostly  constipated. 

ad  7. — Distinct   ascites ;   navel   toughly   infiltrated,   corresponding 


CARCINOMA    OF    THE    STOMACH  217 

to  the  liganicntuiii   tores,  a  finn  cord   running  upward.     Uneven  tumor- 
masses  in  the  cpigastriinn  ;  over  this  covering  a  large  area  "peritoneal" 
friction.     Traces  of  retromalleolar  edema, 
ad  8. — Beginning:  Ma}^  1904. 

Status  presens :  October  4,  1904. 

Autopsy:  November  11,  1904. 

Duration:  About  6  months, 
ad  9.^ — Autopsy:  Pyloric  portion  of  stomach  diffusely  infiltrated, 
diminishing  the  lumen  of  the  stomach  and  greatly  constricting  the  py- 
lorus. No  dilatation  of  the  stomach  on  account  of  the  rather  uniform 
infiltration.  Metastases  in  the  peritoneum,  particularly  also  contraction 
in  the  mesentery.  Navel  carcinomatosis  of  the  peritoneum.  Often  also 
the  ligamentum  teres  can  be  felt  as  a  toughly  infiltrated  cord.  Extensive 
"peritoneal"  friction-sounds,  audible  in  the  epigastrium,  also  betrays 
peritoneal  involvement. 

Absence  of  gastric  dilatation,  despite  severe  pyloric  stenosis  with 
continuous  vomiting,  may  be  due  to  diffuse  infiltration  of  the  gastric 
walls. 

Case  54.— Z.  F.,  39  years,  M. 

ad  1. — IMother  died  of  intestinal  cancer. 

ad  2. — Between  the   ages   of  15   and  24,   frequent  epistaxis. 

ad  3. — No  I.  D.  C.     As  a  child,  always  well  and  strong. 

ad  4. — One  morning,  when  22  years  of  age,  felt  slightly  unwell, 
whilst  riding,  felt  a  mild  diffuse  stabbing  anteriorly  in  the  chest,  fell  to 
the  ground  unconscious ;  is  said  to  have  been  unconscious  for  8  days,  on 
awakening  nose  and  mouth  filled  with  blood.  He  was  told  that  "an  artery 
had  burst."  Had  no  gastric  or  pulmonary  complaints;  after  14  days 
felt  perfectly  well. 

In  the  autumn  of  1892,  when  27  years  of  age,  had  for  some  days 
anorexia;  on  the  third  or  fourth  day,  jaundice  appeared,  and  a  few  days 
later  there  were  colic-like  pains  in  the  right  half  of  the  abdomen.  Dur- 
ing the  past  8  years,  on  and  off,  chills  without  any  other  accompanying 
symptoms. 

ad  6. — In  January,  1904,  a  lump  of  clotted,  black  blood  was  dis- 
charged with  the  stool,  being  enveloped  in  thick  mucous  and  accom- 
panied by  some  tenesmus.  In  May,  1904,  the  appetite  grew  worse;  im- 
mediately after  eating  stabbing,  cramp-like  pains  underneath  the  left 
costal  arch,  especially  also  on  deep  breathing.  Stomach  is  said  to  have 
been  somewhat  distended  frequently.  Since  May,  1904,  his  weight 
dropped  from  TO  kg  to  50  kg.  Tendency  to  frequent  fluid  bowel  evacua- 
tions. Stools  of  a  very  bad  odor.  In  right  lateral  position  there  is  a 
feeling  of  something  shifting  from  left  to  right.  After  one  glass  of  milk 
immediate  stabbing  underneath  the  left  costal  arch  and  a  feeling  of  im- 
peded breathing.  These  symptoms  last  four  to  five  minutes,  then  there 
follow  colic-like  pains  in  the  left  lower  abdominal  region.  One  to  two 
hours  after  the  noonday  meal,  fluid  bowel  evacuation.  No  eructation,  no 
heartburn,  no  vomiting.     For  the  past  month  pains  underneath  the  left 


218  TUMORS    OF    THE    ABDOMINAL    VISCERA 

costal  arch  on  deep  breathing,  stooping,  reaching  for  some  object  with 
the  left  hand.  During  the  past  weeks  colicky  pains  in  the  left  half  of 
the  abdomen,  accompanied  by  loud  gurgling;  left  half  of  the  abdomen 
distended  and  tense. 

Immediately  after  defecation,  severe  pains  in  the  left  half  of  the  abdo- 
men. In  the  beginning  of  December,  1904,  the  appetite  improved,  had 
predilection  for  sour  potato  salad.  The  patient  is  aware  of  peculiar, 
continuous  splashing  sounds  underneath  the  left  costal  arch,  which  pre- 
vent him  from  sleeping. 

ad  7. — Tongue  slightly  coated.  Uneven,  hard  tumbr-mass  under- 
neath the  left  costal  arch,  respiration  movable,  over  it  a  tympanitic 
sound.     Pale  yellowish  facial  color. 

Stomach  contents:  After  test  breakfast,  total  acidity,  44-%.  No  sar- 
cinae,  no  lactic-acid  bacilli.  Distention  of  the  colon  produces  pain  un- 
derneath the  left  costal  arch. 

Feces:  Blood-coloring  matter  present;  abundant  cocci,  gathered  to- 
gether in  heaps. 

January  9,  1905:  Overnight,  spontaneous  diuresis  of  5  litres,  and 
furthermore,  disappearance  of  the  edemas  (lower  extremities,  sacrum). 
Leucocytes,  9,630.  During  the  concluding  days  of  life,  violent  headache 
and  meningeal  manifestations  without  any  particular  disturbance  of  con- 
sciousness. 

ad  8. — Beginning:  January,  1904. 

Status  presens:  October  15,  1904. 
Autopsy:  February  12.  1905. 
ad  9. — Autopsy  (Professor  Dr.  0.  Stoerk)  :  Carcinoma  of  the 
transverse  colon  ^*^  the  size  of  a  man's  fist,  ulcerating,  situated  on  the 
upper  wall,  extensively  perforating  it  in  many  places.  Diffuse  purulent 
meningitis  with  the  formation  of  a  scant  cloudy  exudate  (more  abundant 
only  at  the  base  and  distinctly  purulent). 

Bacteriological  finding  (Professor  Dr.  A.  Ghon)  :  Capsule- forming 
streptococcus.  Analogous  finding  in  the  contents  of  abscess  lying  be- 
tween the  stomach  and  colon. 

Epicrisis:  The  non-involvement  of  the  pylorus  (carcinoma  of  the 
greater  curvature)  accounts  for  the  fact  that  symptoms  of  regurgitation 
(eructation,  vomiting)  are  permanently  absent.  Clinically,  one  is  strongly 
inclined  to  assume  that  the  episode  occurring  at  22  years  of  age  (severe 
unconsciousness  with  hemorrhage  from  mouth  and  nose)  was  an  internal 
hemorrhage  from  a  gastric  ulcer  latent  up  to  that  time,  which  later  be- 
came the  base  of  the  developing  cancer. 

Like  the  ulcer,  the  carcinoma  subsequently  ran  a  latent  course.  Only 
involvement  of  the  colon  produces  in  January,  1904,  the  first  alarming 
symptom:  discharge  of  a  lump  of  clotted  blood  in  the  feces  with  slight 
tenesmus.  The  ulcerative  process  in  the  splenic  flexure,  moreover,  ac- 
counts   for   the   tendency   to   copious   liquid   bowel   evacuations    and   the 

'"  It  was  impossible  to  determine  whether  the  colon  or  the  stomach  was  the  place 
of  origin. 


CARCINOMA    OF    THE    STOMACH  219 

peculiarity  of  the  intestinal  flora  (pronounced  appearance  of  large  heaps 
of  cocci!).  As  the  pyloric  passage  remains  latent  there  is  no  growth  of 
lactic-acid  bacilli. 

The  sudden  appearance  of  spontaneous  polyuria  (5,000  cm)  about 
one  month  prior  to  demise,  with  regress  of  the  edemas,  nuist  be  put  down 
as  a  fact ;  it  is  difficult  to  account  for  it  in  any  satisfactory  way. 

The  last  stage  of  the  disease  process,  a  meningitis,  due  to  capsule- 
forming  streptococci,  may  have  been  of  abdominal  origin. 

Case  55. — A.  N.,  53  years,  F. 

ad   1. — Mother  died  of  some  pulmonary  disease. 

ad  3. — No  I.  D.  C. ;  later  also  ahvays  well. 

ad  6. — In  July,  1903,  one-quarter  hour  after  eating  meat,  violent 
pain  in  the  lower  half  of  the  abdomen ;  the  pain  becoming  worse  after 
another  quarter  of  an  hour;  vomiting  of  the  ingested  foods,  together 
with  much  mucous  and  some  bile ;  vomiting  afforded  immediate  relief.  If 
the  patient  eats  nothing  there  is  bulimia;  as  soon  as  she  begins  to  eat 
the  sensation   of  hunger  ceases. 

ad  1  .■ — Hard  tumor  at  the  p>'lorus.  Left  low^er  abdominal  re- 
gion and  left  flank  decidedly  bulging,  corresponding  to  the  greatly  di- 
lated stomach,  which  is  in  peristaltic  unrest.  Collapse  of  the  bulging 
portions  after  severe  eructation  of  gases.  The  vomitus  contains  abun- 
dant lactic-acid  bacilli.  Some  time  after  operation,  appearance  of  a 
putrid  exudate  in  the  left  pleural  space,  containing  abundant  colon  ba- 
cilli.   Leucocytes,  29,000. 

ad  8. — Beginning:  July,  1903. 

Status  presens:  October  23,  1904. 
Operation :  November  3,  1904. 
Autopsy:  November  29,  1904. 
Duration :  4  months. 

ad  9. — Operation  f  Docent  Dr.  H.  Lorenz)  :  Carcinoma  as  big  as  a 
fist  at  the  pylorus.  Pea-size  metastases  in  the  left  lobe  of  the  liver  and 
metastases  in  the  great  omentum. 

Autopsy  (Professor  Dr.  0.  Stoerk)  :  Carcinoma  of  the  pylorus,  en- 
circling same  (gastro-enterostomy  anterior  17  days  ago)  ;  here  and  there 
metastases  in  the  liver.  Pneumonic  areas  in  the  left  lower  lobe  and  a 
gangrenous  cavity  the  size  of  a  hazel-nut  perforating  into  the  pleural 
space.     Walled-off  putrid  exudate. 

Epicrisis:  Exquisite  intolerance  for  meat.  The  localization  of  the 
pain  produced  in  the  epigastrium  by  eating  meat  is  somewhat  unusual, 
though  it  might  have  some  connection  with  the  low  situation  of  the  greatly 
dilated  stomach.  The  terminal  putrid  pleural  empyema  was  not,  as 
might  have  been  suspected,  an  abdominal  extension,  but  originated  in  a 
gangrenous  area  in  the  lung  (aspiration.''). 

Case  56. — J.  H.,  46  years,  M. 

ad  3.- — No  I.  D,  C. ;  as  a  child,  always  healthy, 
ad  4. — Never  had  stomach  or  intestinal  complaints. 


220  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  6. — Since  Januar}',  1904,  frequent  violent  pain  in  the  region 
of  the  stomach,  radiating  from  the  epigastrium  toward  the  left  breast. 
Appetite  became  bad.  Now  and  then  eructation  with  the  odor  of  SH2. 
September  8-9,  very  severe  pains  to  the  right,  in  the  region  of  the  gall- 
bladder, lasting  uninterruptedly  for  two  days. 

January  13,  1905:  Appetite  good  of  late.  Pain  increased  on  motion, 
radiating  toward  the  anterior  portion  of  the  thorax  and  toward  the  back, 
ad  7. — Indistinct  resistance  in  the  midline  of  the  epigastrium  (No- 
vember 17,  1904).  Tenderness  to  pressure  on  the  right  side,  underneath 
the  costal  arch,  in  the  region  of  the  gall-bladder.  Stomach  dilated,  can 
be  felt  because  of  increased  tension  of  the  walls.  HCl  2%  (after  test- 
breakfast)  :  abundant  sarcinre. 

January  13,  1905:  Distinct  tumor  to  the  right  of  the  umbilicus  and 
traces  of  HCl  (after  test-breakfast)  ;  abundant  sarcinjE. 
ad  8. — Beginning:  January,  1904. 

Status  presens:  November  11,  1904,  and  January  13,  1905. 
Operation:  January  19,  1905. 
Duration :  About  1  year, 
ad  9. — Operation   (Docent  Dr.  A.  Earner):  Tumor  the  size  of  a 
fist,  of  cartilaginous  hardness,  extending  from  the  greater  curvature  to 
the  pylorus ;  infiltration  of  glands  of  the  greater  curvature. 

Epicrisis:  Even  though  in  November,  1904  (operation:  January, 
1905)  the  chemical  and  microscopical  findings  (Hcl  and  sarcina^)  cor- 
responded to  a  benign  stenosis,  the  consideration  that  the  stenosis  (sar- 
cinae !  gastric  meteorism  !)  developed  in  a  short  time  would  speak  for  the 
malignant  nature  of  the  disease.  Despite  the  persistence  of  HCl  secre- 
tion, there  was  no  clinical  ground  to  think  of  a  pre-existing  ulcer.  After 
the  stomach  complaints  had  run  along  for  one  year  tlie  appetite  was 
still  well  preserved. 

Case  57. — K.  W.,  51  years,  F.    Washerwoman. 

ad  3. — In  childhood  had  cholera  and  variola. 

ad  4. — Never  had  gastro-intestinal  disturbances. 

ad  5. — Always  was  well. 

ad  6. — In  July,  1904,  pains  began  in  the  back,  especially  at  night 
and  when  doing  hard  work.  Since  the  middle  of  October,  1904,  continu- 
ous pains  in  the  epigastrium,  worse  at  night  and  after  eating.  After  the 
pains  had  lasted  one  hour  there  followed  nausea  and  vomiting,  partly 
biliary,  once  "coffee-grounds."  Increase  of  symptoms  after  eating  solid 
foods.  Of  late,  therefore,  the  patient  takes  onU'  soup,  milk  and  tea. 
Since  the  beginning  of  the  gastric  pains  anorexia  and  constipation  ;  since 
then  also  paleness  of  the  face  and  emaciation. 

ad  7. — Tumor  in  the  epigastrium,  transmitting  a  strong  pulsatory 
thrill.  Much  tenderness  on  pressure  along  the  right  costal  arch  and  in 
the  region  of  the  right  kidney.  "Coffee-ground"  vomiting,  abundant  lac- 
tic-acid bacilli. 

Urine:  Strong  indican  reaction  {Ohermeyer) .     Death  following  hema- 
temesis. 


CARCINOMA    OF    THE    STOMACH  221 

ad  8. — Beginning:  July,  19()4<. 

Status  prescns :  NovcnibL-r  15,  19()4. 
Autopsy:  May  11,  1905. 
Duration:  10  months, 
ad  9. — Autopsy  (Dr.  K.  Wiesiwr)  :  Constricting  cancer  with  border 
like  a  wall  (ulcer.'')  at  the  pylorus,  extensive  metastases  in  the  periportal, 
mesenteric   and   retroperitoneal  lymph-glands.      Intergrowth   of  stomach 
with  anterior  belly-wall,   with  the   liver   and   with   the  pancreas.      Fresh 
fibrinous  pleuritis  over  the  left  lower  lobe. 

Epicrisis:  Also  in  this  case  the  phenomena  of  pain  come  strongly  into 
the  foreground.  The  initial  symptom  is  pain  in  the  back,  and  its  noc- 
turnal aggravation  is  worthy  of  note.  So  also  the  attacks  of  pain  sub- 
sequently occurring  in  the  epigastrium  and  doubtless  of  gastric  origin, 
exhibit  similar  relations  to  the  hours  of  the  night. 

Early  adhesions  to  the  pancreas  may  enter  into  the  production  of  the 
pains  in  the  back. 

Sensitiveness  on  the  right  side  posteriorly  in  the  kidney  region  is  not 
seldom  met  with  in  connection  with  painful  lesions  of  the  pylorus. 

Case  58. — J.  B.,  51  years,  M.    Machinist. 

ad    1. — Parents  died  from  weakness  of  old  age. 

ad  3.— No  I.  D.  C. 

ad  4. — Stomach  was  always  inclined  to  be  weak ;  milk  poorly  tol- 
erated. 

ad  5. — Always  was  healthy.  His  work  required  him  frequently  to 
brace  instruments  against  the  epigastrium. 

ad  6. — Since  February,  1904,  at  intervals  of  2  to  3  days,  stabbing 
pains  in  the  middle  of  the  epigastrium,  thence  radiating  to  the  right  an- 
teriorly into  the  nipple  of  the  breast  and  at  the  same  time  into  both  sides 
of  the  back ;  duration  of  attacks  mostly  3  hours ;  often  accompanied  by 
feeling  of  chill  and  hiccough.  In  the  beginning  of  September,  1904,  very 
violent  pains,  the  patient  vomited  3  litres  (?)  dark,  coagulated  blood. 
Remained  in  the  hospital  four  weeks  and  was  discharged  as  "cured." 
Eight  days  later  he  returned  to  work.  The  appetite  grew  worse.  From 
December  3d  to  December  24th  gained  3  kg  in  weight.  Bowels  always 
regular.  Appetite  good.  Feeling  of  soreness  in  the  mouth.  After  break- 
fast at  8  o'clock  pains  follow  at  9  o'clock;  frequent  attacks  of  pain  toward 
7  P.M.  During  the  painful  attack  the  patient  acquires  relief  by  walking 
about  or  assuming  the  left  lateral  position. 

ad  7. — Indistinct  resistance  in  the  region  of  the  pylorus ;  there 
and  underneath  the  right  costal  arch  great  sensitiveness  to  pressure.  Per- 
cussion in  the  linea  alba  (epigastrium)  painful.  Tenderness  in  the  right 
axillary  line  at  points  corresponding  to  the  sixth  and  seventh  intercostal 
spaces.  The  vertebral  column  is  sensitive  to  pressure,  two  finger  breadths 
below  the  level  of  the  angle  of  the  scapula  and  thence  downward.  Splash- 
ing in  the  stomach,  which  the  patient  himself  has  noticed  since  the  begin- 
ning of  the  disease,  splashing  occurring  while  walking  about.  Pale  yel- 
lowish f.ace  coloration  (no  icterus). 


222  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Blood:  2,400,()()()  erythrocytes,  4,800  leucocytes,  40%  hemoglobin, 
ad  8. — Beginning,  Februarys  1904. 

Profuse  hematemesis :  September,  1904. 
Status  presens:  February  4,  1905. 
Autopsy:  February  14,  1905. 
Duration:  About  1  year, 
ad  9. — Autopsy  (Docent  Dr.  J.  Bartel)  :  Ulcerating  carcinoma  of 
the  cardiac  end  of  the  stomach  perforating  below,  and  ulcer  of  the  stom- 
ach.     Escape   of  stomach  contents   into   the   abdominal   cavity.      Lapa- 
rotomy two  days  ago  with  establishment  of  a  jejunal  fistula. 

Ejncrisis:  Chronic  trauma  in  the  epigastrium  through  bracing  instru- 
ments against  it. 

Beginning  of  the  disease  with  pyloric  colic  (type:  pseudo-gall-stone 
colic)  ;  hiccough  as  an  accompanying  symptom. 

Seven  months  after  the  beginning  of  the  first  symptoms  there  occurs 
a  profuse  hemorrhage.     Two  months  prior  to  death  there  is  an  increase 
in  weight  of  3  kg.     Death  occurs  with  hematemesis. 
Anatomical  diagnosis :  Ulcus  carcinomatosum. 

Clinically,  in  view  of  the  short  duration  of  the  entire  disease  (one 
year),  unaccompanied  by  symptoms  of  ulcer,  the  thouglit  obtnides  itself, 
whether  the  coming  of  the  ulcer  was  not  associated  with  some  malig- 
nant factor,  so  that  such  cases  would  have  to  be  classified  as  "ulcerous 
cancer." 

For  differential  diagnosis  in  these  and  similar  cases,  only  one  rule 
seems  to  me  applicable.  If,  under  continued  ulcer  therapy  (rest  in  bed, 
regulation  of  bowel  movements  by  means  of  enemas,  diet,  etc.),  the  hemor* 
rhage  does  not  cease,  a  malignant  ulceration  nuist  be  thought  of. 

Case  59. — F.  P.,  32  years,  M.    Baker, 
ad  3.— No  I.  D.  C. 

ad  5. — Was  always  healthy. 

ad  6. — In  March,  1903,  decrease  of  appetite;  especially  after  in- 
gestion of  vegetables,  feeling  of  fulness  in  the  stomach  and  eructatipn, 
with  the  odor  of  decomposition.  No  pains.  Six  months  later  began  to 
vomit  about  one-half  hour  after  meals,  bowels  constipated. 

November,  1903 :  Resection  of  the  pylorus !  The  patient  could  again 
eat  everything,  bowels  became  regular,  gained  10  kg  in  one  month;  felt 
well  until  November,  1904.  Appetite  again  became  bad,  eructation  and 
vomiting  of  bile.  After  meals,  pain  underneath  the  xiphoid  process  and 
on  both  sides  along  the  costal  arches. 

February  16,  1905:  Second  operation,  with  transient  improvement, 
ad  7. — Tongue     conspicuously     red,     smooth,     shiny.     Extensive 
metastases  in  the  liver ;  systolic  murmur  over  the  left  lobe, 
ad  8. — Beginning,* March,  1903. 

.  First  operation :  November,  1903. 
Second  operation:  February  16,  1905. 
Status  presens:  jMarch  15,  1905. 
Duration :  2  years. 


CARCINOMA    OF    THE    STOMACH  22'S 

ad  9. — Finding  at  operation:  Liver  filled  with  tuiuor  nodules;  stom- 
ach could  not  be  hroufrht  into  view  on  account  of  nunurous  adlicsions. 

Kpicrisis:  The  impeded  evacuation  of  the  stomach  leads  to  the  usual 
ascending  scale  of  symptoms:  feeling  of  fulness — eructation — vomiting. 
Deserving  of  note  is  the  "rotting"  odor  of  the  regurgitated  gases  in  con- 
tradistinction to  the  odorless  eructation  in  nervous  dyspepsias. 

Atrophic  changes  in  the  lingual  mucosa  are  not  seldom  met  Avith  in 
cancer  of  the  stomach,  similarU^  as  in  pernicious  anemias.  Over  the  car- 
cinomatously  infiltrated  liver  a  systolic  vascular  murmur.  Although  after 
the  first  operation  there  evidently  remained  behind  some  carcinomatous 
tissue  (relapse  after  three  months),  the  patient  gained  10  kg  in  weight. 

Case  60.— M.  S.,  61  years,  F. ' 

ad  3. — No  infectious  diseases. 

ad  -1. — For  the  past  15  years  frequent  digestive  disturbance  after 
fat  foods,  grain  Hour  foods,  etc. ;  after  a  fcAV  days  of  careful  dieting 
rapid  improvement.     Chronic  constipation. 

ad  5. — Never  seriously  sick;  had  four  normal  confinements. 

ad  6.— Since  the  end  of  March,  1905,  now  and  then,  stabbing  in 
the  left  hypochondrium.  One  morning  in  the  early  part  of  April,  1905, 
sudden  unaccountable  severe  pain  along  the  left  costal  arch,  stabbing 
and  cutting;  patient  could  rest  only  on  her  back.  Increase  of  pain  after 
eating  soup  or  milk.  On  the  same  day,  twice  vomiting  of  coloi-less  mucus. 
Since  then  these  pains  are  constant,  now  and  then  worse  at  night ;  in- 
crease after  ingestion  of  sour  foods.  Feeling  "as  if  a  stone  were  lying  in 
the  stomach."  Pains  radiating  from  the  left  costal  arch  into  the  left  lum- 
bar region,  often  upward  behind  the  sternum,  so  that  the  patient  could 
hardly  breathe.  Constant  pains  in  the  left  side  of  the  back,  also  in  the 
region  of  the  sacrum.  Appetite  bad,  bowels  constipated.  Eructation  of 
mucus  or  air. 

ad  7. — A  tumor-mass  can  be  felt  to  the  left  under  the  costal  arch 
when  patient  is  in  right  lateral  position. 

Seventh  and  eighth  intercostal  spaces  on  the  left  somewhat  sensitive 
to  pressure;  likeAvise  the  left  lumbar  region.  Traces  of  retromalleolar 
edema.  HCl  negative.  Neither  the  vomitus  nor  the  feces  show  lactic-acid 
bacilli  in  larger  quantities. 

Urine:  Indican  reaction  strongly  positive.  Slight  indication  of  a 
diazo  reaction. 

ad  8. — Beginning:  End  of  March,  1905. 
Status  presens:  May  8,  1905. 
Autopsy:  June  8,  1905. 
Duration :  2  months. 

ad  9. — Autopsy  (Docent  Dr.  J.  Bartel)  :  Ulcerating  medullary 
gastric  carcinoma  (not  stenosing)  of  the  lesser  curvature  wnth  large  gland 
metastases  (=  palpatory  finding),  retroperitoneal  and  mesenteric. 
Metastases. in  the  liver.  Left-sided  pleural  effusion.  Struma  of  the  left 
lobe  of  the  thyroid  gland. 

Epicrisis:  The  location  of  the  main  tumor-mass  underneath  the  left 


224  TUMORS    OF    THE    ABDOMINAL    VISCERA 

costal  arch  corresponds  with  the  left-sidedness  of  the  painful  phenomena. 
At  the  same  time  the  left  lumbar  region,  as  well  as  the  seventh  and  eighth 
intercostal  spaces  (axillary),  are  sensitive  to  pressure.  As  a  result  of 
gastric  dilatation  due  to  impeded  evacuation  (despite  a  patent  pyloric 
passage)  there  occur  left-sided  radiations  of  pain.  Growth  of  lactic- 
acid  bacilli  is  absent. 

The  tumor  palpable  during  life  did  not  correspond  to  the  gastric  can- 
cer itself  but  to  the  metastatic  glandular  infiltration  in  the  lesser  cur- 
vature. 

Case  61.— H.  H.,  37  years,  F. 

ad  1. — Parents  are  living  and  healthy;  mother  has  gravel  in  the 
urine. 

ad  3. — Measles  at  5,  whooping  cough  at  7.  After  the  fourth  con- 
finement pains  in  the  abdomen,  chills,  icterus,  inflammation  of  both  knee- 
joints;  duration:  4<  months. 

ad  4. — From  28  to  30  years  of  age,  almost  daily  vomiting  of  mu- 
cus and  poor  appetite  (formerly  had  a  very  good  stomach).  No  nervous 
complaints.  Frequent  heartburn  and  odorless  eructation.  Pains,  stab- 
bing in  character,  underneath  the  left  costal  arch,  radiating  into  both 
shoulder-blades.  Pains  also  when  perfectly  at  rest.  After  same  a  swell- 
ing is  said  to  have  been  often  palpable  underneath  the  left  costal  arch, 
often  disappearing  suddenly  (peristalsis.'*).  Sour,  gas-forming  and  spicy 
foods  were  avoided.  Perfect  cure  after  Karlsbad  cure.  During  the  fol- 
lowing 5  years  pain  in  the  stomach  occurred  seldom,  now  and  then,  prior 
to  menstruation. 

ad  6. — Since  November,  1904,  frequent  pains  underneath  the  left 
costal  arch.  Since  January,  1905,  pallor  and  emaciation;  anorexia  and 
constipation.  Frequent  eructation  with  odor  of  SH2.  In  January,  1905, 
albumin  found  in  the  urine ;  since  the  middle  of  May,  1905,  edema  in  both 
lower  extremities. 

January,  1905:  Tenderness  on  pressure  underneath  the  left  costal 
arch  so  that  the  patient  could  no  longer  wear  her  abdominal  bandage. 

In  February,  1905,  the  pains  became  more  intense,  were  also  located 
posteriorly  on  the  right  side  at  a  point  corresponding  to  the  lower  limits 
of  the  lung,  and  radiated  from  the  back  into  both  scapulae.  Pain,  espe- 
cially at  7  p.^r.,  sometimes  lasting  through  the  whole  night,  accompanied 
by  a  feeling  of  pressure  and  tension,  extending  upward  toward  both 
scapulfe;  relief  after  eructation  or  discharge  of  gases.  Anesthesia  inter- 
nally had  a  favorable  effect  on  these  painful  conditions. 

ad  7.- — Indistinct,  somewhat  firm  resistance  underneath  the  left 
costal  arch ;  much  sensitiveness  underneath  the  left  costal  arch  on  light 
percussion  (May  26,  1905). 

June  6,  1905:  No  tenderness  underneath  left  costal  arch;  tumor  more 
distinct,  cylindrical,  permits  of  slight  ballottement.     Extreme  pallor. 
Feces:  Abundant  sarcinjp. 

Urine:  Indican  reaction  strongl}^  positive.  Albumin  3%,  few  hyaline, 
granular  and  small  waxy  casts. 


CARCINOMA    OF    THE    STOMACH  225 

Blood:  Hemoglobin,  30%,  leucocytes,  19,800;  few  normoblasts, 
ad  8. — Beginnincr:  November,  1904. 

Status  presens:  ^lay  26,  1905. 
Autopsy:  June  27,  1905. 
Duration:  About  8  months, 
ad  9. — Autopsy  (Professor  Dr.  O.  Stoerk)  :  Ulcerating  carcinoma 
of  the  pyloric  region  of  the  stomach,  having  a  chronic  ulcer  for  its  base. 
Purulent  thrombophlebitis  of  the  portal  vessels.     Diffuse  purulent  peri- 
tonitis.     Severe   parenchymatous   nephritis   and   thrombosis    of   the   left 
renal  vein  and  all  its  branches  within  the  kidney. 

Epicrisis:  From  the  differential  diagnostic  point  of  view  it  deserves 
to  be  mentioned  that  the  patient  was  referred  to  the  clinic  by  a  very  com- 
petent man  with  the  diagnosis  of  a  "left-sided  malignant  tumor  of  the 
kidney."  In  the  history-,  the  patient  stated  that  from  28  to  30  years  of 
age  she  had  been  treated  for  a  floating  kidney  on  the  left  side.  A  careful 
anal^'sis  of  the  s^^mptoms  at  that  time  inclines  one  to  the  belief  that  it 
was  a  gastric  ulcer.  The  nephritic  finding  in  the  urine  was  something 
quite  unusual  in  connection  with  gastric  cancer;  furthermore,  this  left- 
sided  tumor  was  ballottable. 

On  the  other  hand,  the  ensemble  of  pain  had  decided  gastric  earmarks. 
Two  findings  in  particular  were  of  diagnostic  importance : 

1.  Anesthesin,  given  internally,  had  a  remarkable  effect  on  the  exist- 
ing pain,  Avhich,  in  view  of  its  local  anesthetic  action,  speaks  decidedly 
against  renal  painful  conditions.  2.  The  feces,  on  microscopic  ex- 
amination, showed  abundant  sarcin.T,  which  is  a  pre-eminent  gastric 
finding. 

These  were  the  two  main  arguments  against  the  surgical  diagnosis  of 
renal  neoplasm,  and  they  at  the  same  time  enabled  a  correct  diagnosis 
of  gastric  cancer. 

Case  62.— J.  S.,  57  years,  F.     Cook. 

ad   1. — Parents  died  in  advanced  age. 

ad  3. — In  childhood  had  scarlatina. 

ad   4. — Bowels  always  regular. 

ad  6. — Since  autumn  of  1904  pallor  of  the  face,  emaciation,  fa- 
tigue, anorexia  with  disinclination  toward  meat.  In  June,  1905,  transient 
improvement  in  appetite,  but  the  patient  eats  onl}'  vegetables  and  soup. 
In  right  lateral  position  drawing  pains  on  the  left  side  and  moderate  sen- 
sitiveness on  pressure  underneath  the  left  costal  arch. 

ad  7. — Cylindrical  tumor  underneath  the  left  costal  arch,  best  pal- 
pable when  standing  and  in  right  lateral  position,  when  the  tumor  is  in 
the  region  of  the  navel.  With  dorsal  decubitus  the  swelling  disappears 
behind  the  costal  arch  and  can  only  be  felt  somewhat  like  an  enlarged  an- 
terior pole  of  the  spleen  when  that  organ  is  moderately  enlarged.  Over 
the  tumor  a  short  systolic  murnmr.  Slight  edema  in  the  lower  extremi- 
ties and  over  the  sacrum. 

Stool:  Few  long  lactic-acid  bacilli. 

Urine:  Diazo  reaction  temporarily  positive. 


226  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  8. — Beginning:  Autumn,  1904<. 

Status  prescns:  July  20,  1905. 
Operation:  July  27,'  1905. 
Duration:  About  10  months, 
ad  9. — Finding  at  operation  (Dr.  R.  Schmarda)  :  Carcinoma  origi- 
nating in  the  minor  curvature,  infiltrating  the  anterior  wall  of  the  stom- 
ach, extending  backward  in  cone-shape ;  pyloric  portion  free. 

Epicrisis :  This  case  illustrates  how  important  it  is  to  palpate  in  dif- 
ferent body  positions.  When  standing,  the  tumor  is  easily  felt  under- 
neath the  left  costal  arch,  whereas  it  disappears  behind  the  costal  arch 
in  the  dorsal  position.  Examination  in  different  positions  of  the  body  at 
the  same  time  informs  us  of  the  degree  of  mobility,  which  in  the  present 
case  was  extraordinarily  great. 

The  systolic  vascular  murnmr  frequently  heard  over  gastric  tumors 
was  observed  also  in  this  case. 

Case  63.— M.  D.,  47  years,  F. 

ad  1. — Father  died  at  60  of  a  chronic  pulmonary  disease,  mother 
died  of  heart  disease. 

ad  2. — Since  childhood  a  great  deal  of  headache,  except  for  the 
past  two  years.  Two  years  ago  an  "epileptic"  attack  with  unconscious- 
ness.    Hallux  valgus. 

ad  3. — Had  measles,  scarlatina  and  varicella. 

ad  4. — Always  had  a  "weak"  stomach. 

ad  6. — Since  the  end  of  1903,  pains  in  the  left  lumbar  region,  bor- 
ing, deep,  occurring  suddenly  now  and  then.  Duration,  about  one-half 
hour.  Since  the  summer  of  1905  pale  appearance,  fatigue,  fasj:ening 
skirts  is  painful.  In  August,  1905,  black,  liquid  stools.  Feeling  of 
fulness  after  meals,  induced  vomiting  by  tickling  the  throat.  Heartburn. 
Tenderness  to  pressure  in  the  epigastrium  and  posteriorU'  on  the  left 
side,  in  the  region  of  the  kidney. 

ad  7. — Tumor  of  the  pylorus  with  enormous  dilatation  of  the  stom- 
ach and  varying  tension  of  the  gastric  walls.  Toward  the  end  of  expira- 
tion a  distinct  sj'stolic  murmur  in  the  epigastrium,  ^'enous  hums  and 
anemic  heart  murmurs,  ^'omiting  a  quarter  of  an  hour  after  every  meal; 
"coffee-grounds,"  HCl  negative,  abundant  lactic-acid  bacilli. 
Stool:  Abundance  of  lactic-acid  bacilli. 
Blood:  Hgb.  30%. 

ad  8. — Beginning:  End  of  1903. 

Status  presens  :  October  5,  1905. 
Operation  :  October  16,  1905. 
Duration:  About  1  year,  9  months. 

ad  9. — Finding  at  operation  (Docent  Dr.  A.  Exner)  :  Carcinoma 
at  the  pylorus,  almost  occluding  the  lumen ;  glands  in  the  immediate 
proximity  somewhat  enlarged. 

Epicrisis:  Cessation  of  an  habitual  cephalalgia  with  the  beginning  of 
cancerous  disease.  The  pains  localized  in  the  left  lumbar  region  may  be 
considered  the  initial  symptom ;  even  during  the  further  course,  the  left 


CARCINOMA    OF    THE    STOMACH  227 

lumbar  region  remains  sensitive  to  pressure.  Whilst  radiation  of  epigas- 
tric pain  into  the  left  lumbar  region  is  nothing  rare  in  gastric  cancer,  a 
limitation  of  the  pain  to  this  area,  as  here  in  the  beginning,  is  not  a  fre- 
quent observation  and  may  easily  be  misleading. 

Hallux  valgus  as  a  sign  of  abnormal  (uratic?)   metabolism  has  been 
repeatedly  referred  to. 

Case  64. — F.  D.,  53  years,  F.     Servant. 

ad   1. — Parents  died  at  a  very  old  age. 

ad  2.- — No  cutaneous  angiomas.  Two  years  ago  had  intlammation 
of  the  right  shoulder- joint  with  swelling  and  painfulness,  restored  to 
health  in  6  weeks. 

ad  3.— No  I.  D.  C. 

ad  4*. — Since  end  of  September,  1905,  diminished  appetite,  no  an- 
tipathy to  meat,  can  eat  only  small  quantities,  othenvise  feeling  of  pres- 
sure ;  often  odorless  and  tasteless  eructation.  In  the  latter  part  of  Sep- 
tember, 1905,  noticed  in  the  epigastrium  a  swelling  as  big  as  a  little  fist, 
firm,  painless,  movable.     Tumor  not  tender  to  pressure. 

ad  7. — A  tumor  the  size  of  a  fist  in  the  epigastrium  semi-globular, 
movable  in  all  directions,  least  so  downward ;  pulsatory  vibration  ;  tym- 
panitic sound  over  the  tumor.  Underneath  the  xiphoid  process  during 
expiration  loud  systolic  blowing  is  audible.  No  distinct  gastric  peristal- 
sis. Border  portions  of  the  liver  uneven  (operation:  "corset  lobe").  No 
edema  of  the  legs.  Subfebrile  course,  now  and  then  38°  C.  Lactic-acid 
bacilli  in  the  stools. 

ad  8. — Beginning:  End  of  September,  (?)  1905. 
Status  presens :  October  26,  1905. 
Operation:  November  16,  1905. 
Duration:  1^^  months  {?). 
ad  9. — Finding  at  operation  (Uocent  Dr.  A.  Exner)  :  Tumor  the 
size  of  a  fist  at  the  lesser  curvature,  easily  movable  in  all  directions;  the 
entire  omentum  thrown  back  and  in  some  places  adherent  to  the  anterior 
surface  of  the  tumor;  at  the  greater  curvature  several  nut-size  carcino- 
matous glands,  the  same  along  the  lesser  curvature,  up  to  the  cardia; 
metastasis  in  the  liver  bigger  than  a  nut  in  size.     No  evidence  of  stenosis. 
Epicrisis:  If  the  statements  of  the  patient  be  correct,  we  would  have 
to  assume  in  this  case  a  long  period  of  latency.     Here  we  must  also  take 
into  consideration  the  absence  of  pyloric  constriction. 

In  this  case  also  we  may  apply  the  paradox  set  upon  a  former  page: 
The  larger  the  gastric  tumor,  the  less  the  gastric  complaints. 

Even  very  movable  tumors  are  for  obvious  reasons  but  little  moval)lc 
in  a  downward  direction. 

Systolic  epigastric  vascular  murmur! 

Two  years  ago  there  was  an  inflammation  in  the  left  shoulder-joint. 

Case  65. — F.  K.,  44  years,  M.     Farmer. 

ad   1. — Mother  died  of  an  abdominal  tumor. 
ad  2. — Always  strong  and  healthy. 


228  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  3. — Malaria  at  8,  lasting  2  months, 
ad  4. — Never  had  gastric  disturbances  or  constipation, 
ad  6. — Beginning  in  March,  1905,  after  an  error  in  diet  (sauer- 
kraut and  pork)  :  the  following  day  the  stomach  was  distended,  there  was 
pain  and  loud  gurgling,  especially  on  the  right  side.     A  "gastric  catarrh" 
was  assumed,  a  Karlsbad  cure  improved  the  condition  a  little. 

May  18,  1905:  Whilst  lifting  a  heavy  load  had  sudden  violent  pains  in 
the  region  of  the  stomach,  somewhat  to  the  right  of  the  middle  line.  At 
that  time,  the  attending  physician  found  a  swelling  on  the  right  side  in 
the  epigastrium.  Emaciation,  pallor  and  feeling  of  weakness ;  frequent 
night-sweats.  From  March  to  May,  1905,  daily,  one  or  two  attacks  of 
pain  with  distention  of  the  stomach,  lasting  one  to  two  hours,  occurring 
at  different  times  of  the  day  without  any  definite  relation  to  the  intake  of 
food.  Appetite  good,  even  for  meat,  excepting  that  pork  is  badly  tol- 
erated. No  heartburn  or  vomiting.  Bowels  regular.  Pains  often  cramp- 
like, radiating  toward  the  back  and  right  shoulder ;  pain  in  the  back  only 
when  the  pain  anteriorly,  in  the  epigastrium,  is  severe.  With  left  lateral 
position  the  pain  becomes  worse,  together  with  a  sensation  as  if  a  tunior 
was  sagging  to  the  left.  Feeling  of  painful  pulsation  in  the  epigastrium, 
ad  7. — Cylindrical  tumor  in  the  middle  line  of  the  epigastrium, 
hard,  somewhat  nodular,  very  sensitive  to  pressure.  Systolic  "epigas- 
tric" vascular  murmur. 

No  gastric  peristalsis.  Pale  yellowish  facial  color ;  no  edemas.  Poly- 
uria (quantities  of  urine  up  to  3,900  c.c). 

Gastric  contents:  T>actic-acid  bacilli,  short  forms  preponderating. 
Blood:  3,600,000  erythrocytes,  8,400  leucocytes,  25%  hemoglobin, 
ad  8. — Beginning:  March,  1905. 

Status  presens:  November  4,  1905. 
Operation :  November  18,  1905. 
Autopsy:  December  11,  1905. 
Duration :  About  9l/o  months, 
ad  9. — Autopsy    (Hofrat    Professor   Dr.    A.    Weichselbaum)  :  Ul- 
cerating carcinoma  of  the  pyloric  portion  of  the  stomach.     Severe  gen- 
eral anemia. 

Epicrisis:  As  is  so  frequently  the  case,  a  dietetic  is  the  cause  of  the 
first  severe  symptoms;  even  at  that  time  (March,  1905)  the  medical  at- 
tendant should  have  been  urged  to  caution  by  the  simple  consideration 
that  an  individual,  possessing  a  sound  stomach  and  intestines  so  far, 
could  not  possibly  acquire  such  a  stubborn  gastric  disease  from  a  single 
error  in  diet. 

Diagnosis :  "Gastric  catarrh." 
Treatment :  Karlsbad  cure. 

Moreover,  the  prominent  appearance  of  pain  phenomena  ought  always 
to  speak  against  the  diagnosis  of  gastric  catarrh. 

The  lifting  of  a  heavy  load  provokes  intense  pain,  which  is  an  occur- 
rence also  frequent  in  cases  of  ulcer. 

Tli^e  polyuria  observed  in  this  case  is  very  likely  of  anemic  origin 
(Hgb.  25%). 


CARCINOMA    OF    THE    STOMACH  229 

Case  66.— G.  R.,  50  years,  M. 

ad   1. — I'iitlKT  diid  of  tuberculosis. 

ad  3. — No  I.  1).  C. ;  at  l-i  years  of  age  bone  sup})uratioii  in  the 
right  leg  and  thigh  and  right  humerus,  lasting  for  three  years  (Tb.?). 
Later  was  healthy. 

ad  6. — Toward  the  end  of  1902,  three  years  ago,  vomiting  early  in 
the  morning  accompanied  by  cramp-like  pains,  relief  after  drinking  milk. 
At  that  time  the  appetite  was  good,  the  bowels  regular;  since  then  some- 
what inclined  to  be  constipated.  Since  the  end  of  November,  1905,  fre- 
quent feeling  of  pressure  in  the  left  half  of  the  epigfistrium,  especially 
after  farinaceous  foods,  much  less  after  meat,  even  pork.  Impossible  to 
lie  on  the  left  side  because  it  causes  the  appearance  of  pain.  Pains  in 
the  stomach  15  minutes  after  ingestion  of  hard  foods.  Appetite  good, 
but  the  patient  fears  the  pain.  Continuous  pains  in  the  left  lower  ab- 
dominal region,  left  flanks  and  lumbar  region,  radiating  into  the  lower 
axillary  portions  of  the  thorax  (on  the  left). 

ad  7. — Very  firm,  uneven,  tumor-mass  in  the  epigastrium,  the  size 
of  an  apple.  Ascites  of  moderate  degree.  Hard  splenic  tumor,  extending 
to  the  costal  arch.     No  edema. 

After  test-breakfast :  Total  acidity  40%,  HCl  30%. 

Pepsin  4*  mm.     Mette. 
Blood:  4,700,000  erythrocytes,  10,500  leucocvtes,  70%   hemoglobin, 
ad  8.— Beginning:  End  of  1902. 

Status  presens:  December  21,  1905. 
Autopsy:  February  4,  1906. 
Duration :  About  three  years, 
ad  9. — Autopsy:  (Professor  Dr.  0.  Stoerk)  :  Ulcer-like  carcinoma 
situated  in  the  fundus  with  wall-like  borders,  perhaps  springing  from  an 
ulcer,   advancing  toward  the  hilum   of  the   spleen ;  large   glands   in   the 
mesentery. 

Epicrisis:  Cancer  in  an  individual  who,  to  all  appearances,  in  his 
childhood  suffered  from  multiple  caries.  Arrested  tubercular  processes 
are  not  seldom  met  with  even  in  cancer  patients,  but  active  progressing 
tuberculosis  is  extremely  seldom. 

The  first  symptoms  of  disturbed  gastric  function  date  far  back  (  about 
3  years). 

Shortly  prior  to  death  normal  secretory  conditions  of  the  gastric 
mucous  membrane. 

The  intumescence  of  the  spleen  is  explained  in  the  way  of  a  congestion 
(development  of  carcinoma  in  the  hilum  of  the  spleen  with  compression 
of  the  splenic  vein). 

Case  67.— K.  K.,  55  years,  M.     Farmer. 

ad   1. — Fatlier  died  at  6.5  from  some  stomach  disease. 

ad  2.- — Tubercular  habitus  ;  was  alwavs  hcalthv. 

ad  3.— No  I.  D.  C. 

ad   4. — Tolerated  also  fat  aud  sour  foods;  l)owcls  always  regular. 

ad  6. — In  the  beginning  of  November,  1905,  sudden  diarrhea  with- 


L>30  TUMORS    OF    THE    ABDOMINAL    VISCERA 

out  cause,  having  7  to  8  tarry  stools  (had  worked  up  to  the  previous 
day)  ;  the  diarrhea  lasted  14  days.  No  hunger,  no  thirst.  Since  then 
constipation ;  the  patient  can  only  drink  milk. 

December,  1905 :  Lavage  of  the  stomach,  which,  it  is  said,  brought  to 
light  grape  seeds,  which  must  have  been  there  since  October  {?).  One 
hour  after  eating  soup,  a  sensation  of  acidity  in  the  stomach;  very  sour 
eructation. 

ad  7. — Psoriasis  lingual,  upper  surface  of  the  tongue  cracked.     A 
transversely  situated  tumor  in  the  epigastrium  as  thick  as  a  thumb,  hard, 
somewhat  uneven,  giving  a  thrill  on  pulsation.     Stomach  dilated,  spon- 
taneously distended.     Pale  j'ellowish  face  coloration. 
Vomitus,  from  fasting  stomach:  1,500  c.c. 

72%   total  acidity. 
40%  HCl. 
Abundant  sarcinae. 
After  test-breakfa.st  (lavage  preceding)  :  6%  total  acidity. 

36  Vt   HCh 
After  test-l\reakfast  (without  removal  of  residue)  :  72'/t  total  aciditv. 

36%  HCl. 
Withdraimi  stomach  contents  (fasting  stomach)  :  96%  total  aciditv. 

58%  HCl. 
ad  8. — Beginning:  Early  in  November,  1905. 
Status  presens:  January  4,  1906. 
Operation  :  January  6,  1906. 
Autopsy :  January  7,  1906. 
Duration :  2  months, 
ad  9.- — Autopsy  (Docent  Dr.  K.  Landsteiner) :  Carcinoma  of  the 
stomach,  probably  superimposed  on  a  round  ulcer.     Congenital  luxation 
of  the  right   hip-joint   and  deforming  arthritis  of  the  vertebral  column 
with  the  formation  of  exostoses. 

EpicHsis:  Diarrhea  due  to  internal  hemorrhage  as  the  first  symptom! 
Providing  the  statements  of  the  patient  are  correct,  the  cancer  had. 
up  to  that  time,  run  a  latent  course. 

As  in  former  observations,  so  also  here,  the  stagnating  stomach  con- 
tents contain  HCl,  showing  a  high  total  acidity.  After  a  test-breakfast 
taken  on  an  empty  stomach,  HCl  is  absent  and  the  total  acidity  very 
small. 

Clinically,  there  is  no  indication  of  a  pre-existing  ulcer. 

Case  68.— N.  N.,  60  years,  M. 

ad  2. — Has  had  repeated  attacks  of  rheumatism  and  sciatica. 

ad  3. — Of  infectious  diseases  had  only  pericarditis. 

ad  4. — Since  1898,  following  a  dietetic  error,  sensitiveness  of  the 
stomach  with  respect  to  fat  and  sour  foods ;  previous  to  that  he  "could 
have  eaten  gravel."  Since  then  occasional  epigastric  complaints  ascend- 
ing to  the  throat  and  choking.  Bowels  regular.  Improvement  at 
Karlsbad. 

ad  6. — August  18,  1909,  is  given  as  the  date  on  which  the  present 


CAKCIXOMA    OF    THE    STOMACH  2:n 

stouKU-h  troubK'  Ix-ojin  ;  at  tliut  time  hi-  had  stoiiiacli  fi-amps  la.stiii<4-  for 
several  minutes  after  (lrinkiii<^  ehanipagiie  or  Bordeaux.  Appetite  is  good, 
even  at  present  (April,  1910)  ;  nevertheless,  he  has  lost  10  kg  in  weight. 
Chief  complaint  is  pain  having  a  pressing  character,  appearing  almost 
always  when  the  stomach  is  empty,  thus  at  4-  to  5  o'clock  in  the  morning, 
11  o'clock  in  the  forenoon  and  6  o'clock  in  the  afternoon.  The  pain  is 
somewhat  alleviated  by  belching  of  gases,  higestion  of  food  or  a  drink  of 
mineral  Avater.  Position  exerts  no  influence.  Moving  about  in  the  fresh 
air  has  a  favorable  effect.  No  vomiting;  eructation  mostly  tasteless  and 
odorless,  only  on  three  occasions  during  the  disease  was  it  somewhat  sour- 
sweet.  After  eating  there  is  a  feeling  of  pressure  "as  if  he  had  a  dry 
roll  in  his  stomach."  After  taking  acidol-pepsin  the  eructations  and 
other  symptoms  are  somewhat  less ;  Karlsbad  water  had  a  transient  good 
effect.  Bowels  somewhat  tardy.  Those  around  the  patient  are  struck 
by  his  bad  appearance  and  a  yellowish  tint  in  the  color  of  his  face.  Dur- 
ing a  rest  cure  of  14  days  (May,  1910)  gained  V^  kg  in  weight.  On  and 
off  short  stabbing  in  the  region  of  the  costal  arches  and  other  parts  of 
the  abdomen  at  about  4  o'clock  in  the  morning  (after  taking  bismuth) 
and  in  the  afternoon  between  4  and  6  o'clock. 

April,  1910:  Indistinct  resistance  in  the  region  of  the  pylorus;  pres- 
sure in  that  region  somewhat  painful  and  radiating  toward  the  left  costal 
arch.  Withdrawal  of  stomach  contents  after  breakfast  of  tea  and  a 
roll:  Alkaline  reaction  !  Negative  bacteriological  finding.  No  food  resi- 
due from  previous  day.  On  one  occasion  the  withdrawal  was  accom- 
panied by  a  discharge  of  small  fragments  of  mucosa  and  at  the  end,  an 
admixture  of  blood. 

Feces:  On   a  diet   free   from  hemoglobin  the  chemical  test   for  blood 
coloring  matter  was   constantly   positive.      After  ingestion   of  moderate 
quantities  of  fat  many  soaps  were  microscopically  demonstrable, 
ad  8.— Beginning:  August  18,  1909. 

Status  presens:  April  20,  1910. 
Operation:  May  28,  1910. 
ad  9. — Finding  at   operation   (Primarius  Dr.  Palla)  :    A   scirrhus 
carcinoma  almost  encircling  the  pylorus,  without  adhesions  to  surround- 
ing parts,  pylorus  much  stretched  in  an  upward  direction.      The  cancer 
encroaches  more  on  the  lesser  than  on  the  greater  curvature. 

Epicrisis:  Here  again  we  are  dealing  with  an  individual  who  has  al- 
ways had  a  "powerful  stomach."  He  "could  have  eaten  gravel,"  a  state- 
ment so  frequently  made  by  patients  suffering  from  cancer  of  the  stomach. 
Clinically  this  case  could  be  considered  as  of  the  "sensible"  type  in  con- 
tradistinction to  the  "motor"  type  in  which  latter  symptoms  of  stagna- 
tion, resulting  from  impeded  motility,  come  into  the  foreground. 

In  this  case  there  are  hardly  an}'  demonstrable  symptoms  of  disturbed 
mobility.  No  vomiting,  no  food  residue  from  the  preceding  day,  no  lactic 
acid  bacilli.  The  evacuation  of  the  bowels  also  is  but  little  retarded. 
Appetite  pretty  good. 

On  the  other  hand  "lumger  pains"  occur  about  tliree  times  a  day,  and 
these  pains  being  interpreted  so  frequently  as  gastric  neurosis  or  hyper- 


232  TUMORS    OF    THE    ABDOMINAL    VISCERA 

acidity,  are  often  misinterpreted.  For  in  the  preponderating  majority  of 
these  cases  we  are  dealing  with  ulcerative  diseases  of  the  stomach  mostly 
of  a  benign  nature.  But  this  case  and  similar  ones  show  that  also  with 
malignant  ulcerations,  and  with  absence  of  HCl,  an  empty  stomach  may 
lead  to  pain,  and  food  intake  may  bring  relief. 

Emaciation  in  spite  of  a  good  appetite  is  worthy  of  note.  This  might 
be  attributed  to  secondary  disturbances  in  the  digestive  tract  (pancreas? 
intestinal  secretions.'^).  The  deficient  fat  reduction  is  a  not  infi*equent 
finding  demonstrable  also  in  this  case  (with  moderate  ingestion  of  fat 
and  without  diarrhea),  shown  under  the  microscope  by  the  presence  of 
soaps  in  the  feces. 

Case  69.— M.  W.,  56  years,  F, 

ad  1.^ — Mother  died  at  45  of  tuberculosis,  father  died  at  70. 
Brothers  and  sisters  living  and  well. 

ad  3. — Typhoid  at  15 ;  articular  rheumatism  at  22,  lasting  3 
months. 

ad  4. — Stomach  trouble  for  the  past  15  years.  Intolerance  for 
sour  and  fat  foods  and  heavy  vegetables ;  frequent  feeling  of  pressure 
relieved  by  eructation,  improvement  after  taking  magnesia  usta. 

ad  5. — Six  confinements;  12  years  ago  hemorrhages  from  a  myoma 
(  histerectomy  ) . 

ad  6. — For  the  past  two  years  pain  in  the  back  when  cooking, 
washing  or  baking.  Since  Christmas,  1905,  without  error  in  diet,  feeling 
of  fulness  in  the  stomach  "as  if  it  had  to  burst,"  feeling  of  pressure  be- 
hind tlie  xiphoid  process  and  posteriorly  in  the  back;  since  then  constipa- 
tion. Appetite  unchanged.  Frequent  hiccough ;  now  and  then  regurgi- 
tation of  a  "mouthful  of  water  without  taste."  At  night  often  severe 
nausea.      Lingual  mucosa  on  the  left  side  somewhat  atrophic. 

ad  7. — Tumor  in  the  epigastrium  sensitive  to  pressure,  the  size  of 
a  nut,  transversely  situated.      No  edemas. 

ad  8. — Beginning:  February,   1904. 

Status  presens:  February  9,  1906. 
Operation:  February  17,  1906. 
Duration :  About  3  years. 

ad  9. — Finding  at  operation  (Docent  Dr.  A.  Exner)  :  Stomach 
contracted  to  the  size  of  a  small  sausage-shaped  tumor,  involving  the 
entire  stomach,  except  a  small  portion  of  the  greater  curvature ;  besides, 
hard  glands,  the  size  of  beans,  up  to  the  cardia. 

Epicrisis:  One  of  those  rather  rare  instances  in  which  the  carcinoma 
attacks  "gastric  weaklings,"  in  whom  there  is,  as  a  result,  the  absence  of 
the  rapid  decline  in  the  function  of  the  stomach  which  in  "gastric  ath- 
letes" suggests  in  and  of  itself  the  thought  of  gastric  cancer. 

Stabbing  pains  in  the  back,  as  they  existed  also  when  the  disease 
was  fully  developed,  may  here  be  considered  the  initial  symptom.  Stub- 
born hiccough  always  deserves  attention  ;  aside  from  neuroses,  it  is  not 
seldom  found  in  constricting  processes  of  the  pylorus.  This  case  also 
exhibits  atrophic  changes  of  the  lingual  mucosa   (on  one  side). 


CARCINOMA    OF    THE    STOMACH  233 

Case  70.— A.  B.,  50  years,  F. 

Hcl  1. — Father  died  at  30  of  some  thoracic  disease,  mother  and  2 
sisters  healthy. 

ad  3. — Measles  in  childhood;  severe  influenza  in  1890,  also  high 
fever  and  bronchitis  in  May,  1905. 

ad  4. — Alwaj's  had  a  sensitive  stomach,  was  a  small  eater;  feeling 
of  pressure  after  ingesting  a  big  meal.  In  1871  severe  gastric  trouble 
though  having  a  good  appetite;  for  one  year,  between  2  and  3  p.m.  daily 
complaints ;  aggravated  by  smoking. 

ad   5. — Frail  in  childhood,  often  had  catarrh. 

ad  6. — For  the  past  year  and  a  half  unusual  noises  in  the  abdomen. 
In  May,  1905,  feeling  of  pressure  in  the  epigastrium  after  eating.  Appe- 
tite became  bad.      Slight  tenderness,  on  pressure,  in  the  abdomen. 

ad  7.- — Ascites.  No  distinct  tumor  palpable.  Pale  yellowish  facial 
color.  Temperature  mostly  36°C.  Left-sided  apical  infiltration;  apex 
of  the  heart  displaced  toward  the  middle  line.  Soft,  pale  edemas  of  the 
lower  extremities  and  over  the  sacrum.  On  and  off,  liquid  bowel  evac- 
uations. 

ad  8. — Beginning:  August,  190-i. 

Status  presens:  February  26,  1906. 
Autopsy :  March  7,  1906. 
Duration:  About  1  j^car,  7  montlis. 

ad  9. — Autopsy  (Docent  Dr.  K.  Landsteiner)  :  Scirrhus  carcinoma 
of  the  p3'loric  portion  of  the  stomach,  infiltrating  a  portion  of  the  fundus 
and  constricting  the  pylorus.  Scirrhus  metastases  in  the  peritoneum 
with  contraction  of  the  mesentery.  Granular  tuberculosis  of  the  lungs. 
Cavity  in  the  right  upper  lobe,  induration  in  left  upper  lobe  containing 
cheesy  foci.  Adenoma  and  cholesterin  containing  cyst  of  the  thyroid 
gland. 

Epicrisis:  The  previous  stomach  disease  is  hard  to  judge;  it  may  have 
been  an  ulcer.  One  could  hardly  make  a  mistake  in  dating  the  beginning 
of  the  cancer  development  at  the  time  of  the  appearance  of  the  abnormal 
noises  in  the  abdomen.  A  stomach  which  is  the  seat  of  a  scirrhus^"  is 
usually  in  great  motor  unrest,  easily  giving  rise  to  borborygmi. 

As  frequently  happens  in  scirrhus  cancer,  so  also  here,  the  possibility 
of  tubercular  peritonitis  was  taken  into  consideration,  the  more  so,  as  in 
addition  to  ascites  (without  a  palpable  tumor)  there  was  present  tuber- 
culosis of  the  pulmonary  apices. 

The  entirely  afebrile  course  was  remarkable  and  of  differential  diag- 
nostic importance. 

Case  71.— L.  W.,  42  years,  F. 

ad  3. — Had  scarlatina  and  measles. 

ad  5. — Since  the  beginning  of  December,  1905,  abdominal  com- 
plaints; at  the  end  of  that  month  a  left-sided  ovarian  tumor  ("edematous 
fibroma"),  about  the  size  of  a  child's  head,  was  removed;  dismissed  as 

"  See  Cases  2,  6  and  12. 


234.  TUMORS    OF    THE    ABDOMINAL    VISCERA 

cured  on  January  11,  1906;  a  few  days  later  violent  pains  limited  to  the 
left  side,  yielding  to  electrical  treatment  in  14  days. 

ad  6. — In  the  early  part  of  March,  1906,  stabbing  pains  in  the  left 
ischium,  also  in  the  right,  constant,  worse  at  night ;  turning  in  bed  im- 
possible. Since  then  no  appetite.  Bowels  regular.  Anterior  superior 
spine  on  both  sides  \eyy  sensitive  to  pressure,  likewise  the  lower  portion 
of  the  sternum. 

ad  7. — No  tumor  in  the  epigastrium.  Spleen  extends  to  the  costal 
arch,  is  moderately  firm.  Venous  hums  and  loud  anemic  murmurs  over 
the  heart.  Pale  color  of  the  face;  no  edemas.  Small  glands  in  the  left 
supraclavicular  fossa.  Blood:  Erythrocytes,  3,050,000 ;  leucocj^tes, 
5,400;  Hgb.,  .50%.      No  nucleated  red  cells' 

ad  8. — Beginning:  INIarch,   1906. 

Status  presens:  March  26,  1906. 
Autopsy:  April  23,  1906. 
Duration :  About  2  months. 

ad  9. — Autopsy  (Docent  Dr.  A'.  Lnnrlsteiner)  :  Callous  ulcer  scar 
with  carcinoma  in  the  region  of  the  pylorus,  large  metastatic  glands  in 
the  lesser  curvature,  likewise  in  the  left  supraclavicular  fossa.  Severe 
general  anemia.  Bilateral  hydrothorax.  Femur  the  seat  of  many 
metastases!  Absence  of  uterus  and  its  adnexa  (removed  threi-  months 
ago). 

Epicrisis:  One  of  those  cases  of  gastric  cancer  in  which  the  first  clin- 
ical symptoms  are  produced  by  metastases.  May  not  the  ovarian  tumor 
removed  in  December,  1905,  have  been  a  metastatic  formation?  From 
the  history  it  was  impossible  to  decide  with  certainty. 

Clinically  there  entered  into  the  foreground  the  pains  in  the  bones 
of  the  pelvis  which,  as  compared  with  the  sternal  pains,  frequent  also  in 
this  case  and  hardly  ever  met  with  even  in  very  severe  anemias.  Therefore 
bone  metastasis  was  much  more  likely  to  be  thought  of  than  "anemic" 
pains  in  bone.  The  glands  in  the  left  supraclavicular  fossa  pointed  to 
gastric  carcinoma  in  the  first  place. 

Case  72.— L.  Th.,  40  years,  F. 

ad  3. — No  infectious  diseases.  In  childhood  and  later  on  always 
healthy. 

ad  4. — Fat  and  sour  foods  always  well  tolerated;  bowels  mostly 
constipated. 

ad  6. — In  August,  1905,  without  any  dietetic  error  gastric  com- 
plaints started;  nausea;  no  pains,  no  vomiting.  Appetite  good  until 
now.  No  disgust  for  meat.  August  25,  1905 :  Patient  was  operated  on 
for  a  left-sided  ovarian  cyst ;  stomach  complaints  temporarily  improved. 
In  October,  1905,  again  stomach  trouble;  nausea  and  pain  after 
eating. 

In  December,  1905,  beginning  of  vomiting,  mostly  at  about  7  p.m. 
Increased  emaciation.  Feeling  of  pressure  about  6  hours  after  the  noon- 
day meal ;  soar  eructation  and  nausea. 

ad  7. — Transversely  situated  swelling,  about  as  thick  as  a  thumb. 


CARCINOMA    OF    THE    STOMACH  235 

underneath  the  xiplioid  process,  without  tenderness.     Surcinrc  present  in 
feces  and  stomach  contents. 

On  a  fasting  stomach:  300  cm^   residue.      50%   total   acidity.      HCl 
positive.     Lab  and  pepsin  positive. 

Test-hreaKfast   (after  lavage)  :   10%   total  acidity.      HCl   negative, 
ad  8. — Beginning:  August,  1905. 

Status  presens:  March  31,  1906. 
Operation:  April  5,  1900. 
Duration:   About  8  months, 
ad  9. — Finding  at  operation  (Docent  Dr.  P.  Albrecht)  :  Carcinoma 
of  the  anterior  wall  of  the  stomach  near  the  pyloric  portion,  being  about 
15  cm  long  and  8  cm  wide,  also  encroaching  both  the  greater  and  lesser 
curvatures.     Resection  of  the  p3dorus  and  posterior  gastro-enterostomy. 
Epicrisis:  In  this  case  again  the  initial  complaints  resulting  from  the 
cancer  of  the  stomach  were  probably  ascribed  to  the  secondary  ovarian 
tumor,  and  led  to  a  useless  operation.     The  rapid  development  of  pyloric 
stenosis   (sarcinae)    in  and  of  itself  must  have  suggested   a  malignancy. 
As  in  former  cases, ^*  the  residue  obtained  in  the  morning  from  a  fasting 
stomach  shows  a  higher  total  and  HCl  acidity  than  the  contents  with- 
drawn after  a  test-breakfast  with  preceding  lavage  of  the  stomach ;   in 
the  latter  case  there  is  achlorh^'dria. 

Appetite  was  constantly  present;  no  disgust  for  meat. 

Case  73.— A.  W.,  33  years,  F. 

ad  3. — No  infectious  diseases, 
ad  5. — Always  was  healthy. 

ad  6. — In  June,  1904,  there  began  attacks  of  pain  in  the  epigas- 
trium, together  with  distention  and  radiation  of  the  pains  into  the  left 
lumbar  region  and  left  scapula;  at  that  time  also  hematemesis.  Since 
June,  1905,  anorexia.  Recently  black  stools ;  on  one  occasion  the  patient 
could  see  nothing  for  five  minutes.  Constipation.  Belching  of  gas  with- 
out any  sour  taste.  Intolerance  particularly  for  meat ;  also  for  sour 
and  gas-forming  foods — e.g.,  cabbage.  Only  milk  is  well  tolerated.  For 
the  past  few  days  pains  in  the  left  calf,  and  on  motion  also  in  the  out- 
ward side  of  the  left  hip. 

ad  7.— A  palpable  tumor,  about  the  size  of  a  nut,  in  the  region  of  the 
pylorus,  likewise  underneath  the  left  costal  arch;  at  the  latter  place  a 
blowing  systolic  murmur,  especially  at  the  end  of  expiration.  Gastric 
peristalsis  is  visible  when  the  attacks  of  pain  have  reached  their  height. 
Great  pallor  of  the  face,  no  edemas.  Slight  rises  in  temperature  up  to 
38"  C.  On  the  left  side,  posteriorly  below,  crepitation  of  atelectasis. 
Vomiting  of  "coffee-grounds,"  abundant  lactic-acid  bacilli. 

Stool:  Abundant  lactic-acid  bacilli. 

Urine:  Diazo  reaction  positive. 

Blood:  24,000  leucocytes. 

Muscles  of  the  left  calf  sensitive  to  pressure,  swollen,  with  increased 

>'See  Case  67. 


236  TUMORS    OF    THE    ABDOMINAL    VISCERA 

temperature  in  that  area;  likewise  painfulness  on  pressure  in  the  outer 
left  hip. 

ad  8. — Beginning:  June,  1904. 

Status  presens:  June  4,  1906. 
Autopsy:  June  13,  1906. 
Duration:  About  2  years, 
ad  9. — Autopsy  (Docent  Dr.  J.  Bartel)  :  Soft  constricting  carci- 
noma of  the  pylorus  with  infiltration  of  the  regional  glands,  three  car- 
cinomatous nodules  in  the  liver.     Severe  anemia.     Thrombosis  of  the  left 
crural  vein. 

Epicrisis:  One  of  those  rather  rare  cases  in  which  hematemesis  counts 
among  the  initial  sj^mptoms. 

Two  years  before  death  painful  attacks  after  the  type  of  "colic  of 
pyloric  stenosis,"  with  left-sided  localization. 

Findings  of  atelectasis  over  the  left  lower  lobe  are  not  rarely  met 
with  in  connection  with  gastric  dilatations.  As  often  before,  a  systolic 
"epigastric  vascular  murmur." 

Positive  diazo  reaction !  This  finding  is  rare  in  gastric  .cancer,  and 
then  seems  to  occur  most  frequently  with  the  medullary  forms,  likewise 
a  high  leucocyte  count  (24,000). 

Case  74.— R.  K.,  58  years,  F. 

ad  3. — Typhoid  at  1-5  years  of  age. 

ad  4. — Stomach  always  very  good ;  fat  and  sour  foods  also  were 
always  w^ell  tolerated. 

ad  5. — Was  always  healthy. 

ad  6. — In  August,  1905,  while  stooping,  she  noticed  that  gases  or 
fluids  regurgitated;  the  latter  Wfis  mostly  tasteless,  at  times  somewhat 
sour;  since  then  constipation.  In  the  beginning,  despite  the  eructation, 
could  tolerate  everything,  except  that  she  had  a  little  pressure  in  the 
epigastrium.  At  present  only  milk  and  broth  are  well  borne.  No  pain, 
no  tenderaess  on  pressure. 

ad  7. — Ascites ;  edema  in  the  lower  extremities.  Tumor  not  pal- 
pable. 

Stomach  contents:  Abundant  lactic-acid  bacilli. 
Urine:  Indication  of  a  diazo  reaction. 

July  18th:  During  the  night  sudden  severe  pains,  abdomen  painful 
on  pressure,  pulse  cannot  be  felt,  no  increase  in  temperature ;  death  in 
the  evening. 

ad  8. — Beginning:  August,  1905. 

Status  presens :  June  26,  1906. 
Autopsy:  July  18,  1906. 
Duration:  About  11^/2  months, 
ad  9. — Autopsy    (Professor   Dr.    0.   Stoerk)  :   Diffuse   infiltrating 
carcinoma,  springing  from  the  pylorus.     Bilateral  nodular  metastatic  in- 
filtration of  the  ovaries.     Acute  fibrinous  peritonitis  resulting  from  per- 
foration of  the  stomach   (at  the  point  of  perforation  an  ulceration,  the 
size  of  a  penny,  not  x>i  carcinomatous  origin). 


CARCINOMA    OF    THE    STOMACH  237 

Epicrisis:  Aiuoiig  the  initial  symptoms  of  the  case  we  find  the  peculiar- 
ity that  in  stooping  the  pressure  exerted  on  the  stomach  leads  to  a 
regurgitation  of  gastric  gases  and  fiuids  ("expressible  stomach"). 

The  diazo  reaction  is  remarkable.  Both  ovaries  are  the  seat  of  meta- 
static formations.  Death  as  a  result  of  a  non-carcinomatous  small  gastric 
perforation. 

Case  75.— M.  L.,  67  years,  F. 

ad  1. — Of  5  brothers  and  sisters,  -i  died  of  pulmonary  tuberculosis 
between  40  and  50  years  of  age. 

ad  2. — Two  3'ears  ago  there  appeared  what  seemed  to  be  nodes  of 
Hebcrden  in  the  terminal  phalanges  of  the  fingers,  accompanied  by  pain, 
ad  3. — Xo  infectious  diseases. 
ad  4. — Appetite  always  good,  bowels  regiilar. 
ad  5. — Was  always  healthy;  climacteric  at  50  years  of  age. 
ad  6. — Since  the  end  of  November,  1905,  little  appetite,  great  dis- 
inclination toward  meat.     Bowels  tardy.     Since  April,  1906,  she  noticed 
a  swelling  in  the  right  side  of  the  abdomen;  right  lateral  position  impos- 
sible; after  every  meal  a  painful  feeling  of  pressure;  pains  in  the  back 
on  the  right  side,  especially  when  Ij'ing  down,  less  so  when  sitting  up ; 
therefore  sits  up  many  nights.     For  the  past  week  general  eczemas. 

ad  7. — Extensive  nodular  tumor-masses  in  the  right  half  of  the 
abdomen,  vibrating  with  pulsation,  and  over  them  a  tympanitic  percus- 
sion sound ;  similar  tumor-masses  also  on  the  left  side,  underneath  the  cos- 
tal arch.  Umbilicus  firmly  infiltrated.  Severe  edema  of  both  lower  ex- 
tremities. 

Blood:  Leucocytes,  10,800;  large  mononuclear  forms,  18%;  hemo- 
globin, 70%. 

ad  8. — Beginning:  November,  1905. 

Status  presens :  June  27,  1906. 
Autopsy:  June  28,  1906. 
Duration:  8  months, 
ad  9. — Autopsy  (Professor  Dr.  0.  Stoerli)  :  Diffuse  medullary  in- 
filtration of  the  pylorus,  general  metastasis  in  the  peritoneum  and  regional 
glands  (liver  free  from  metastases).     Histological  finding:  Carcinoma. 

Epicrisis:  The  appearance  of  the  nodes  of  Heberden  would  seem  to 
coincide  in  time  with  the  beginning  of  the  cancerous  disease  or  precede 
it  shortly.  This,  as  well  as  the  general  eczema,  appearing  a  short  time 
before  death,  may  be  looked  upon  as  a  "dyscrasia." 

The  violent  pains  in  the  back,  especially  on  the  right  side,  are  refer- 
able to  the  carcinomatous  finding. 

The  tough  infiltration  of  the  umbilicus  ^^  deserved  to  be  mentioned  as 
a  partial  manifestation  of  the  general  peritoneal  metastasis. 

The  high  percentage  of  large  mononuclear  forn>«  is  worthv  of  note, 
as  it  is  found  much  more  frequently  in  lympho-sarcomatous  processes. 

"See  Case  53. 


238  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  76.— C.  W.,  62  years,  F. 

ad   1. — Father  died  of  pulinonary  tuberculosis. 

ad  3. — No   infectious  diseases. 

ad  4. — Always  had  good  digestion,  bowels  regular. 

ad  5. — Always  was  healthy. 

ad  6.- — In  the  beginning  of  April,  1906,  sudden  profuse  diarrhea, 
lasting  about  one  week,  without  pain ;  general  health  good.  Since  the 
end  of  April,  1906,  at  first  2  hours,  later  5  to  7  hours  after  meals,  heart- 
burn ;  at  the  same  time  constipation  began.  Since  then  also  copious  vom- 
iting, preceded  by  cramp-like  pains  in  the  lower  abdomen,  extending  to 
the  epigastrium  and  radiating  into  the  dorsal  and  lumbar  regions ;  daily 
vomiting.  Stubborn  constipation  (lasting  up  to  10  days!).  Liquid  food, 
e.g.,  milk,  oggs,  is  more  easily  vomited,  solid  food  being  generally  better 
tolerated. 

The  following  are  tolerated:  Soup,  green  vegetables,  some  beefsteak, 
broilers,  light  flour  foods,  tea,  cocoa.  With  right  lateral  decubitus  in- 
crease of  pain  and  radiation  along  the  esophagus,  this  leading  to  vomiting 
more  easily. 

ad  7. — Superficial  tumor  at  the  level  of  the  umbilicus.  Frequent 
gurgling  in  the  stomach.  Loud  5»plashing.  Color  of  the  face  pale,  no 
edemas.  "Coffee-ground"  vomiting  with  a  total  acidity  of  50%  ;  HCl, 
30%  ;  pepsin,  10  mm. 

Blood:  Hgb.,  50%;  erythrocytes,  4,400,000;  leucocytes,  10,000. 

ad  8. — Beginning:  Early  part  of  April,  1906. 
Status  presens:  June  27,  1906. 
Operation:  July  5,  1906. 
Duration:  About  3  months. 

ad  9. — Finding  at  operation  (Docent  Dr.  H.  Lorenz)  :  A  fairlv 
movable  tumor,  the  size  of  an  apple,  tough,  nodular.  Colon  transversum 
fixed  to  the  tumor;  glandular  metastases  in  the  omentum  and  mesocolon. 
Gastro-cnterostomy  retrocolica  posterior. 

Epicrisis:  As  among  others  in  Case  75,  where  four  brothers  and  sis- 
ters died  of  tuberculosis,  so  also  here  there  is  a  record  of  tuberculosis, 
namely,  in  the  father;  my  personal  impression  coincides  with  that  of  other 
observers,  namely,  that  tuberculosis  is  frequent!}^  met  with  among  the 
ancestors  and  relations  of  cancer  patients. 

Among  the  initial  symptoms  we  find  unaccountable  diarrhea,  soon  giv- 
ing way  to  most  stubborn  constipation.  The  latter  Ix'havior  may  be  con- 
sidered the  rule  in  gastric  cancer. 

Belonging  to  the  early  symptoms  of  the  case,  we  also  find  heartburn, 
which  may  probably  be  considered  as  a  symptom  of  stagnation ;  during 
the  further  course  there  are  "colics  of  pyloric  stenosis."  HCl  secretion 
is  demonstrable  even  shortly  before  operative  interference.  The  exceed- 
ingly large  quantity  of  pepsin  is  deserving  of  note. 

Case  77.— E.  Z.,  57  years,  M. 

ad   1. — Father  died  in  advanced  age. 

ad   4. — Had  a  very  good  stomach,  could  tolerate  the  heaviest  foods. 


CARCINOMA    OF    THE    STOMACH  -239 

;ul  (). — Sincx'  uhout  July,  1904,  increasing  anorexia  and  weakness 
of  tlie  stomach  ;  had  to  he  very  careful,  because  otherwise  f^astric  pres- 
sure would  set  in. 

Januar}^,  1905:  .\ttack  of  pain  in  the  epigastrium,  about  three 
hours  after  the  noon-day  meal,  radiating  toward  the  left,  sometimes  also 
toward  the  right  costal  arch,  lasting  several  hours.  Frequent  heartburn. 
\()  vomiting.  Bowels  moved  daily.  Since  May,  1906,  distention  of  the 
alxlomen  synchronous  with  the  attacks  of  pain,  the  distention  disappear- 
ing with  the  pain.  White  meat,  chopped  into  snifUl  bits,  is  tolerated  best. 
Left  lateral  position  proves  most  comfortable  during  an  attack  of  pain. 

ad  7. — A  hard,  very  sensitive  resistance  in  the  middle  of  the  epi- 
gastrium.    No  edemas.     Melena. 

Blood:  Erythrocytes,  3,100,000;  leucocytes,  5,600;  Hgb.,  48'/f  •    Aery 
numerous  blood  platelets. 

ad  8.- — Beginning:  July,  1904. 

Status  presens:  July  7,  1906. 
Operation:  July  13,  1906. 
Duration:  About  2  years. 

ad  9.- — Finding  at  operation  (Docent  Dr.  A.  Exner)  :  At  about 
the  middle  of  the  lesser  curvature  a  cicatricial  contracted  spot,  the  size 
of  a  nut,  which  has  undergone  hardening  (carcinoma).  In  the  mesentery 
of  the  colon  transversum,  hard  glands,  bigger  than  hazelnuts,  and  thence 
a  diffuse  infiltration  of  the  mesocolon  transversum.  No  stenosis  of  the 
pylorus.     Inoperable. 

Epicrisis:  This  case  runs  its  course  without  vomiting  and  without 
constipation.  The  absence  of  both  symptoms  might,  in  part,  be  at- 
tributed to  the  lack  of  a  constriction  of  the  pyloinis.  It  is  well  known 
that  pyloric  constrictions  are  almost  always  accompanied  by  constipation. 
Even  without  actual  stenosis  of  the  pylorus,  the  propulsion  of  the 
gastric  contents  may  be  seriously  interfered  with  when  a  portion  of  the 
wall  is  put  out  of  commission  functionally,  and  then  there  may  occur 
attacks  of  pain  which  are,  par  excellence,  characteristic  of  pyloric  sten- 
osis. 

In  this  case  there  is  no  anorexia  toward  meat ;  in  fact,  white  meat,, 
appropriately  minced,  is  tolerated  best.  • 

Case  78.— F.  A.,  75  years,  F. 

ad   1. — Both  parents  died  at  a  very  old  age. 

ad  2.- — Eight  years  ago  had  pains  in  the  terminal  phalanges  of 
the  fingers,  at  present  these  bones  are  swollen  after  the  manner  of  Hcber- 
den's  nodes. 

ad  3.— No  I.  D.  C. 

ad  4. — At  50  A'^ears  of  age  mild  gastric  complaints,  e.g.,  poor  tol- 
erance for  sausage;  in  other  respects  the  stomach  was  very  good,  even 
fat  and  sour  foods  being  well  borne. 

ad  5. — Up  to  the  time  she  was  15  years  of  age,  suffered  much  from 
hcadiiche,  had  to  wear  a  green  eye-shield.     Later  was  always  well,  strong 


240  TUMORS    OF    THE    ABDOMINAL    VISCERA 

and  looked  well.      For  many  years  has  had  large  varicose  veins  in  the 
legs. 

ad  6. — At  Christmas,  1905,  beginning  of  periumbilical  burning 
pains,  radiating  toward  the  pit  of  the  stomach ;  pains  irregular,  now 
and  then  remaining  absent  for  several  days,  and  even  weeks.  Good  appe- 
tite then  as  now;  tolerates  everything.  No  eructation,  no  vomiting. 
Since  April,  1906,  the  patient  noticed  a  swelling,  about  the  size  of  an 
apple,  in  her  abdomen,  and  at  a  place  corresponding  to  the  swelling,  daily 
pains  radiating  into  the  back.  Continuous  pains,  at  times  becoming  ag- 
gravated and  accompanied  by  gurgling,  radiating  from  the  umbilicus 
toward  the  epigastrium  and  extending  from  there  into  the  back.  Appe- 
tite good ;  never  vomited. 

ad  7. — Somewhat  prominent  tumor,  about  the  size  of  an  apple,  to 
the  right  of  the  umbilicus,  hard,  nodular,  possessing  respiratory  mobil- 
ity, tympanitic  resonance,  decided  pulsatory  vibration.  Systolic  vascular 
murmur  underneath  the  xiphoid  process.  Traces  of  retromalleolar  edema. 
Temperature  often  over  37°  C. 

Feces:  Abundant  lactic-acid  bacilli. 

ad  8. — Beginning:  December.  1905. 

Status  presens:  July  13,  1906. 
Operation :  July  23^,  1906. 
Duration :  About  7  months. 

ad  9. — Finding  at  operatfon  (Docent  Dr.  P.  Alhrecht)  :  Lesser 
curvature  extending  almost  to  the  level  of  the  navel,  taken  up  in  its  lower 
portion  by  a  firm,  rough  tumor,  being  about  the  size  of  an  e^g,  reaching 
almost  to  the  pylorus,  firmly  adherent  to  the  head  of  the  pancreas. 

Epicrisis:  Here,  also,-"  we  have  Heberden's  nodes  as  a  stigma  of 
dyscrasia.  Periumbilical  attacks  of  pain  as  early  symptoms.  Systolic 
"epigastric"  vascular  murmur.  Appetite  conserved  until  immediately 
before  the  operation,  no  meat  anorexia. 

Case  79.— S.  G.,  48  years,  M. 
ad  3.— No  I.  D.  C. 

ad  4. — Never  had  any  gastric  complaints,  was  not  a  strong  eater; 
'ate  many  onions  and  garlic. 

ad  5. — Always  was  healthy. 

ad  6. — In  November,  1905,  after  having  ingested  an  unusually 
large  amount  of  food,  had  a  feelino;  of  pi'cssurc  in  the  stomach ;  later, 
also,  after  a  smaller  intake  of  food.  Appetite  became  diminished,  but 
could  still  eat  everything.  Ill-smelling  eructation.  In  April,  1906,  he 
began  to  frequently  vomit  brown  masses,  even  without  having  eaten  anv- 
thins".  In  the  summer  of  1906  he  went  to  Karlsbad,  after  which  he  felt 
considerably  improved.  In  September,  1906,  several  glands,  which  sup- 
purated. aDpeared  in  the  left  supraclavicular  fossa  and  also  in  the  left 
axilla.     The  patient  was  sent  to  an  iodin  bath  in  Galicia.     At  that  time 


Compare  Case  75. 


CARCINOMA    OF    THE    STOMACH  241 

the  appetite  was  already  bad.    Vomiting  once  a  week.     Constipation  since 
November,  1906. 

ad  7. — A  hard  tumor,  about  the  size  of  a  nut,  underneath  the  right 
costal  arch.  Much  dilatation  of  the  stomach  and  distinct  gastric  peri- 
stalsis. Glands  on  the  left  side  of  the  neck  and  one  gland  deeply  situated 
behind  the  left  clavicle,  moderately  firm  bunch  of  glands  in  the  left  axilla, 
suppurated.     No  edemas ;  no  angiomas. 

Stomach  contents,  fasting:  500  cm^,  dark  brown,  bad  odor. 

41%   total  acidity. 
20%  HCl. 
Repeated  withdrawal  (fasting):  38%  total  acidity. 

8%  HCl. 
After  test-hreakfast:  12%  total  acidity. 

3%  HCl. 
Microscopic  examination:  Many  sarcIn.-E  and  a  few  single  lactic-acid 
bacilli.     Constant  hiccough  and  eructation  of  SH2. 
ad  8. — Beginning:  November,  1905. 

Status  presens :  November  7,  1906. 
Operation:  November  19,  1906. 
Duration:  About  1  year, 
ad  9. — Finding  at  operation  (Docent  Dr.  H.  Lorenz)  :  Constrict- 
ing carcinoma  of  the  pylorus.     Posteriorly  the  pylorus  is  adherent  to  the 
pancreas,    superiorly   with   the   ligamentum   hepato-gastricum.      Gastro- 
enterostomy retrocolic. 

Epicrisis:  The  commonplace  symptom  of  gastric  pressure  introduces 
the  manifestations  of  disease.  Whenever  this  occurs  in  an  individual 
previously  having  a  sound  stomach,  it  should  never  be  neglected,  the  more 
so  when  it  exhibits  distinct  progressiveness  (in  the  beginning  only  after 
large  quantities  and  later  after  even  smaller  quantities  of  food).  As  is 
so  frequently  the  case,  the  patient  was  sent  to  Karlsbad  instead  of  to  the 
surgeon.  The  patient  says  there  was  considerable  improvement!  Such 
improvements  of  a  transitory  kind,  though  exceptionally,  do  occur;  evi- 
dently it  is  the  gastritis,  often  accompanying  the  cancer,  which  experi- 
ences the  improvement. 

The  appearance  of  glands  in  the  left  supraclavicular  fossa  and  in  the 
left  axilla  probably  suggested  a  tubercular  process ;  the  patient  was  or- 
dered to  an  iodin  bath. 

Metastases  in  the  glands  of  the  left  supraclavicular  fossa  are  not  an 
altogether  rare  finding  in  the  later  stages  of  gastric  cancer,  at  any  rate 
not  so  rare  as  metastases  in  the  axillary  glands. 

One  is  strongly  inclined  in  this  case  to  think  of  gland  metastases ; 
the  suppuration  of  the  glands,  though,  is  strange,  as  it  is  practically 
never  observed  in  carcinomatous  glands.  Two  possibilities  suggest  them- 
selves. Either  there  was  a  transportation  of  pus-cells  from  the  ulcerat- 
ing tumor  at  the  same  time  that  the  cancerous  cells  were  transported  or 
there  may  have  been  pre-existing  tubercular  glands  in  which  the  cancer 
metastasis  gave  rise  to  suppuration. 

There  is  persistence  of  HCl  secretion.     It  is  most  clearly  demonstrable 


242  TUMORS    OF    THE    ABDOMINAL    VISCERA 

in  the  stagnating  masses  withdrawn  from  the  fasting  stomach  (irritant 
effect  of  the  products  of  decomposition!),  the  mild  irritation  of  the  test- 
breakfast  elicits  only  HCl  secretion. 

Sarcin^e  prevail  among  the  vegetations. 

Case  80.— D.  D.,  58  years,  F. 

ad  3. — Measles  at  7,  otherwise  no  I.  D.  C. 

ad  -i.- — Has  had  stomach  trouble  since  she  was  30  years  of  age ;  fre- 
quent gastric  pressure,  especially  in  winter,  less  in  summer.  Complaints 
come  on  after  prolonged  fasting,  but  also  after  eating;  sitting  is  un- 
favorable, motion  favorable.  Intolerance  toward  milk  (better  borne  when 
taken  with  coffee)  and  grain  flour  foods ;  often  induces  artificial  vomiting 
after  meals.     Constipation  began  when  50  years  of  age. 

ad  6.—  Since  the  middle  of  September,  1906,  increase  of  the  former 
stomach  complaints.  Heartburn.  Attacks  of  pain  radiating  from  the 
epigastrium  into  the  right  thorax,  especially  one  or  two  hours  after  the 
noonday  meal,  relief  after  vomiting;  during  tlie  painful  attack  right 
lateral  position  is  impossible.  Constipation.  Disgust  for  meat;  nourishes 
herself  with  milk,  soup  and  vegetables.  Slight  tenderness  on  pressure  to 
the  right,  above  the  navel. 

ad  7. — Stomach  dilated,  splashing  sounds  and  spontaneous  bor- 
borygmi.     No  visible  peristalsis. 

Stomach  contents:  Abundant  sarcinse,  HCl  distinctly  demonstrable. 
Feces:  Tarry,  containing  abundant  leptothrix  threads, 
ad  8. — Beginning:  September,  1900. 

Status  presens:  November  14,  1906. 
Operation:  November  21,  1906. 
Duration:  About  2  months, 
ad  9. — Operation  (Decent  Dr.  P.  Albrecht)  :  Carcinoma  constrict- 
ing the  pylorus,  involving  the  duodenum  to  the  extent  of  one  cm  and  ad- 
herent to  the  pancreas.     Gastro-entcrostomia  rctrocolica  posterior. 

Epicrisis:  One  of  the  comparatively  rare  cases  in  which  the  cancer 
does  not  develop  in  the  midst  of  the  best  health,  but  seems  to  be  brought 
on  after  years  of  gastric  symptoms  (ulcer.''). 

Though  inspection  does  not  reveal   increased  gastric  peristalsis,  the 
existence  of  lively  spontaneous  stomach  roaring  points  to  the  hindrance 
at  the  pylorus,  which  is  made  evident  by  the  finding  of  sarcinae.     The 
right-sided  "painful  position"  also  is  of  pyloric  origin. 
Persistence  of  HCl  secretion. 

Case  81.— Th.  J.,  55  years,  F. 

ad  3.- — Diphtheria,  scarlatina,  measles. 

ad  4.— Appetite  always  very  good ;  never  any  stomach  complaints, 
-ad  6.^ — Since  January,  1906,  feeling  of  pressure  in  the  epigastrium, 
especially  after  ingestion  of  sweet  foods.  Appetite  good  at  the  start,  no 
eructation.  Since  October,  1906,  has  vomited  about  30  times.  During 
the  last  few  months  there  appeared,  especially  on  the  anterior  portion  of 
the  thorax,  a  brownish  discoloration  in  spots.     Severe  emaciation  of  late. 


CARCINOMA    OF    THE    STOMACH  243 

After  intake  of  food  pains  in  the  back,  particularly  when  there  is  simul- 
taneous feeling  of  pressure  in  the  epigastrium. 

ad  7. — A  hard,  uneven  tumor-mass  can  be  felt  underneath  the  left 
costal  arch,  especially  when  the  patient  is  in  right  lateral  position.  The 
liver  is  tender  on  percussion,  enlarged,  and  has  a  nodular  surface;  a  "cor- 
set lobe,"  filled  with  nodules,  yields  distinct  ballottement.  The  spleen 
extends  to  the  costal  arch.  No  edemas.  The  skin,  especially  over  the 
anterior  portion  of  the  chest,  is  pigmented  dark  brown, 
ad  8. — Beginning:  January',  1906. 

Status  presens:  January  5,  1907. 
Autopsy:  February  11,  1907. 
Duration :  About  1  year. 
ad  9. — Autopsy   (Hofrat   Professor  Dr.  A.   Weichselbaum)  :  Dif- 
fuse scirrhus  carcinoma,  involving  the  greater  part  of  the  stomach,  to- 
gether with  contraction  and  diminution  in  its  size.     Metastases   in   the 
neighboring  lymph-glands,  in  the  great  omentum,  peritoneum  and  pleura, 
also  in  the  liver.     Compression  of  the  portal  vein  and  the  ductus  chole- 
dochus  by  contracting  cancer  tissue.     Hydrops-ascites.    Icterus.    Atrophy 
of  the  right  adrenal  body  and  partial  incrustation  of  its  capsule.     Brown 
discoloration  of  the  skin  of  the  thorax. 

Epicrisis:  The  pigmentations  of  the  skin,  which  formed  in  the  last 
months  of  the  disease,  are  worthy  of  note.  As  they  were  of  an  Addisoni- 
an character,  attention  was  given  to  the  condition  of  adrenals  at  autopsy, 
and  it  was  found  that  the  right  adrenal  body  had  become  contracted 
through  imbedding  in  indurated  cancerous  tissue.  Quite  analogous  pig- 
mentations, however,  are  also  met  with  in  connection  with  other  neoplasms 
leading  to  cachexia  (especially  pancreas) ^^  without  any  changes  in  the 
adrenal  bodies. 

As  almost  always  happens  with  the  scirrhus  type  of  gastric  cancer,  so 
also  here,  there  is  carcinomatosis  of  the  peritoneum. 

There  are  present  lumbar  pains  which  depend  on  the  intake  of  food, 
and  are  of  the  same  genesis  as  the  epigastric  feeling  of  pressure. 

Case  82.— L.  Sch.,  42  years,  M. 

ad  3. — Smallpox  and  diphtheria. 

ad  6. — Since  March,  1906,  feeling  of  pressure  in  the  epigastrium, 
especially  after  eating,  lasting  about  14  of  ^^  hour,  in  the  beginning  ap- 
pearing at  intervals  of  one  week ;  gradual  increase  of  this  feeling  of 
pressure.  Often  three  to  four  Huid  stools.  Of  late  anorexia,  constipa- 
tion. During  the  last  three  weeks,  rapidly  increasing  bulging  in  the 
region  of  the  liver;  for  several  days  past  feverishness  and  herpes  labialis. 
During  the  last  few  days  could  tolerate  only  right  lateral  position  with 
knees  drawn  up,  every  change  in  position  exceedingly  painful.  Often  sud- 
denly occurring  pressing  pains  in  the  epigastrium,  at  the  same  time  also 
in  the  back. 

ad  7. — Liver  distinctly  enlarged,  very  sensitive  to  pressure,  bor- 

"  See   page  44. 


244  TUMORS    OF    THE    ABDOMINAL    VISCERA 

der  very  firm;  distinct  systolic  vascular  murmur  audible  over  the  liver. 
Dilated  veins  cross  the  right  costal  arch.     Pallor  of  the  face ;  no  edemas. 
Transient  temperature  of  39.4°   C.  and  herpes  labialis. 
Urine:  much  urobilinogen. 
Blood:  11,000  leucocytes. 

ad  8. — Beginning:  March,  1906. 

Status  presens :  January  5,  1907. 
Autopsy:  January  22,  1907. 
Duration:  About  10  months, 
ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Soft,  medullary  carci- 
noma of  the  stomach  at  the  lesser  curvature,  not  constricting,  in  the  form 
of  papillary  proliferations.     Diffuse  metastases   in  the  liver  with  peri- 
hepatitis.    Several  polypi  in  the  gastric  mucosa.    General  icterus. 

Epicrisis:  Symptoms  referable  to  the  liver  came  so  prominently  into 
the  foreground  that  for  a  time  the  possibility  of  a  cholelithiasis  with 
abscess  formation  as  well  as  an  echinococcus  infection  was  thought  of. 

On  account  of  the  perihepatitis,  the  patient  had  to  remain  immo- 
bilized in  the  right  lateral  position,  every  change  in  position  being  ex- 
tremely painful. 

High  fever  up  to  39.4,  accompanied  by  an  herpetic  eruption,  could 
lead  one  to  think  of  an  infectious  process  in  the  liver.  Chemically,  the 
metastasis  in  the  liver  found  expression  in  the  urine  by  the  appearance 
of  a  strongly  positive  aldehyde  reaction  (urobilinogen). 

Case  83.— F.  L.,  50  years,  F. 

ad  3. — Had  scarlet  fever  at  5  years  of  age. 

ad  6. — Since  the  middle  of  September,  1906,  pains  during  meals 
behind  the  lower  third  of  the  sternum,  later  on  along  the  left  costal  arch 
and  to  the  left  of  the  sternum;  relief  after  vomiting.     The  patient  was 
hungry,  but  did  not  eat  for  fear  of  the  pain.    Pain  in  the  back  on  motion, 
ad  7. — Tongue   very   much   coated.      Epigastrium   somewhat   ten- 
der on  pressure,  so  also  the  region  of  the  spleen ;  no  palpable  tumor.     No 
edemas;  particular  abundance  of  angiomatous  formations. 
Gastric  contents:  Abundance  of  lactic-acid  bacilli. 
Urine:  Strongly  positive  aldehyde  reaction, 
ad  8. — Beginning:  September,  1906. 

Status  presens:  January  16,  1907. 
Autopsy:  January  29,  1907. 
Duration:  About  4l/o  months, 
ad  9. — Autopsy  (Hofrat  Professor  Dr.  A.  Weicliselhaum)  :  Diffuse 
scirrhus  of  the  stomach  with  constriction  of  same  and  diminution  in  size. 
Metastases  in  the  great  omentum  and  peritoneum  with  much  contraction 
of  the  mesentery  of  the  small  intestinal  loops.      Sero-fibrinous  peritonitis 
and  a  fresh  pleurisy  on  the  left.   Numerous  concretions  in  the  gall-bladder 
which  was  about  the  size  of  a  goose  egg. 

Epicrisis:  As  an  early  symptom  the  previous  history  records  retro- 
sternal sensations  occurring  after  meals,  which  might  occasionally  be  mis- 
interpreted as  angina  pectoris. 


CARnXOMA    OF    THE    STOMACH  245 

The  strongly  positive  aldehyde  reaction  in  the  urine  in  this  case  is 
not  explained  by  the  metastases  in  the  liver,  but  in  the  accompanying 
cholelithiasis. 

Case  84.— Sch.  S.,  40  years,  M. 

ad  3. — Malaria  at  8  (lasting  6  months).  In  1879,  30  years  ago, 
syphilis   (inunction  treatment). 

ad  4. — Up  to  six  years  ago  never  had  any  gastro-intestinal  disturb- 
ances. Six  years  ago  the  appetite  became  bad ;  after  eating  sauerkraut 
or  "fisolen"  there  was  a  feeling  of  fulness  in  the  stomach  followed  by 
vomiting,  later  also  intolerance  toward  meat  and  flour  foods. 

ad  6. — Since  March,  1906,  there  are  pains  of  a  pressing  character 
and  vomiting  after  every  meal.  During  the  painful  attacks  the  epigas- 
trium is  distended  and  loud  rolling  is  audible.  Constipation,  alternating 
with  diarrhea.  During  the  last  three  weeks  the  vomiting  has  ceased; 
since  then  there  is  a  disinclination  toward  tobacco  (  formerly  30  cigarettes 
daily).  For  the  past  three  weeks  a  small  swelling  is  noticeable  in  the 
epigastrium.  During  the  past  six  months  cramp-like  pains,  especially 
after  the  intake  of  solid  foods. 

ad  7. — A  transversely  running  cord  can  be  felt  underneath  the  left 
costal  arch.  Manifestations  of  atelectasis  on  the  left  side  posteriorly 
below.      No  edemas. 

After  test-breakfast:  HCl,  negative;  total  acidity,  2%.  Mo  N.  Na. 
OH.     No  lactic-acid  bacilli. 

Blood:  5,900,000  erythrocytes,  7,600  leucocytes,  75%  Hgb. 
Quantity  of  urine:  Between  2,000  and  3,000  cm^. 
ad  8. — Beginning:  March,  1906. 

Status  presens :  January  17,  1907. 
Operation :  February  9,  1907. 
Duration:  About  11  months, 
ad  9. — Finding  at  operation   (Docent  Dr.  H.  Lorenz)  :  Anterior 
wall  of  the  stomach  partly  occupied  by  firm  uneven  tumor,  which  extends 
into   the   pyloric    region    and   encroaches    on   the   posterior   wall    of   the 
stomach.   Numerous  glandular  metastases  in  the  small  and  large  omentum. 
Epicrisis:  Dilatation  pains  of  the  stomach,  together  with  distention 
of  same  and  "rolling,"  play  an  important  part  from  the  beginning  also 
in  this  case.     Lactic-acid  bacilli  are  absent,  despite  the  advanced  stage 
of  the  disease. 

Atelectasis  in  the  left  lower  lobe  of  the  lung.  Tendency  to  polyuria; 
edemas  are  absent. 


Case  85.— W.  B.,  42  years,  M. 

ad   1. — Mother  alive,  73  years  old. 

ad  3. — No  infectious  diseases. 

ad  4. — Always  had  a  good  appetite,  bowels  regular;  also  fatty,  sour 
and  gas-forming  foods  were  well  borne ;  always  had  a  preference  for 
strongly  spiced  foods. 


246  TUMORS    OF    THE    ABDOMINAT.    VISCERA 

ad  5. — On  account  of  bodily  weakness  was  exempted  from  military 

service ;  is  said  to  have  coughed  up  blood  for  several  weeks,  17  years  ago. 

ad  6. — Since  October,  1906,  feeling  of  pressure  after  eating,  often 

sour  eructation,  constipation.      Only  milk  and  soup  are  tolerated.      ]\Ieat 

is  immediately  vomited. 

Feeling  of  pressure  in  the  region  of  the  stomach,  radiating  under  the 
costal  arches  on  both  sides. 

ad  7. — With  left  lateral  position  a  tumor  can  be  felt  deep  under- 
neath the  right  costal  arch,  sensitive  to  pressure.  Dilatation  of  the 
epigastric  veins.  Epigastrium  bulging,  tense.  A  hard,  enlarged  gland 
in  the  left  supraclavicular  fossa.  No  edemas,  ^'omitus  contains  sar- 
cin«e  and  a  moderate  abundance  of  lactic  acid  bacilli. 
ad  8. — Beginning:  October,   1906. 

Status  presens :  February  25,  1907. 
Operation:   February   "28,    1907. 
Autopsy:  March  27,^1907. 
Duration  :  About  6  months. 
ad  9. — Operation  (Docent  Dr.  H.  Lorenz):  Cancer  at  the  pylorus 
with  metastases  in  the  mesocolon  and  mesentery.     Chylous  ascites. 

Autopsy  (Professor  Dr.  O.  Stoerk)  :  Carcinoma  of  the  pylorus  en- 
croaching on  the  duodenum  with  severe  stenosis  at  that  place.  Gastro- 
enterostomy 14  days  ago.  Extensive  metastases  on  the  peritoneum,  in 
the  liver,  in  the  mesenteric  and  retroperitoneal  lymph-glands.  Ascites 
chylosus.      Scars  in  the  left  pulmonary  apex. 

Epicrisis :  In  his  youth  the  patient  had  been  alHicted  with  a  mild  form 
of  tuberculosis  (hemoptysis),  the  remains  of  whicii  showed  up  at  autopsy 
as  an  induration  in  the  left  pulmonary  apex. 

Here  again  the  disease  begins  in  the  midst  of  good  health  with  "gas- 
tric pressure." 

The  syndrome  "ascites  and  left-sided  supraclavicular  hard  gland" 
soon  informs  us  of  the  nature  of  the  process.  The  "milky"  character 
of  the  ascitic  fluid  desei-ves  attention. 

Case  86. — A.  H.,  39  years,  M.    Mason. 

ad  3. — Varicella. 

ad  4. — At  14  years  of  age,  after  eating  meat,  had  violent  stomach 
cramps  (sick  for  10  days)  ;  since  then  intolerance  toward  blackbread, 
hard  meat,  fat.      Appetite  always  good.      Bowels  regular. 

ad  6. — Beginning  about  the  middle  of  February,  1907,  with 
troublesome  sour  eructations,  appetite  then,  as  now,  was  good,  bowels 
regular  up  to  the  present  time.  For  the  past  14  days  pain  on  the  left 
underneath  the  costal  arch ;  cannot  lie  on  his  left  side.  Pain  after  every 
intake  of  food,  even  after  milk.      Epigastrium  very  sensitive  to  pressure. 

ad  7. — On  the  left,  underneath  the  costal  arch,  a  firm  tumor  about 
the  size  of  a  walnut ;  over  it  a  loud  systolic  blowing  during  expiration. 
Numerous  enlarged  glands  in  the  left  supraclavicular  fossa,  but  none 
anywhere  else. 

After  test-hreakfast:  HCl  negative,  a  few  short  lactic-acid  bacilli. 


CARCINOMA    OF    THE    STOMACH  247 

Blood:  5,900  kucocytcs. 
Urine:  Diazo  reaction  positive. 

ad  8. — Beginning:  February,  1907. 
Status  presens:  May,  1907. 
Operation:  June  6,  1907. 
Duration :  About  3  months, 
ad  9.^ — Finding    at    operation    (Doccnt    Dr.    P.    Albrecht)  :    Hard 
tumor  about  the  size  of  an  egg,  springing  from  the  lesser  curvature  of  tlie 
stomach,  intergrown  with  the  under  surface  of  the  liver;  retroperitoneal 
gland  metastases. 

Epicrisis:  The  combination  of  the  two  symptoms,  epigastric  vascular 
murnmr  and  diazo  reaction,  almost  make  certain  the  diagnosis  of  a  malig- 
nant disease,  and  to  these  there  is  still  added  the  presence  of  one  of  \'ir- 
chow's  glands.      Appetite  good;  bowels   regular. 

Case  87.— L.  W.,  45  years,  M. 

ad  1 . — Father  died  at  70,  mother  at  68  years  of  age ;  neither  cancer 
nor  tuberculosis  in  the  family. 

ad  2. — As  a  child  inclined  to  be  weak. 

ad  3. — No  infectious  diseases  of  childhood ;  in  1885  had  a  "menin- 
geal typhoid"  for  8  weeks. 

ad  -i. — Since  having  typhoid  there  is  an  intolerance  toward  bloat- 
ing foods  and  fat  meat;  no  heartburn,  but  often  gastric  pressure  and 
bowel  troubles. 

ad  6. — Since  January,  1909,  therefore  for  about  II4  years,  often 
flatulence  and  borborygmi,  pain  in  the  lower  abdominal  region,  easily  con- 
stipated. Appetite  bad,  frequent  eiaictation,  of  late  having  the  odor  of 
"rotten  eggs."  Since  the  end  of  February,  1910,  appetite  completely 
vanished,  much  distention  in  the  epigastrium,  much  rumbling  in  the  belly. 
On  deep  breathing  there  are  painful  sensations  in  the  epigastrium,  also 
frequent  attacks  of  cramps  lasting  only  a  few  seconds,  coming  on  about 
two  to  three  hours  after  meals,  occasionally  appearing  also  at  night  so 
that  the  patient  is  awakened  from  sleep.  From  February  19th  of  this 
year  to  INIarch  31st  the  patient  has  lost  8  kg.     Never  any  vomiting. 

ad  7. — Color  of  the  face  not  cachectic,  no  edemas,  a  very  distinct 
arcus  senilis.  Tongue  not  coated.  Epigastrium  somewhat  tender  to 
pressure,  especially  in  the  middle  line ;  no  splashing  sounds.  No  resistance 
can  be  felt  even  after  repeated  examination.  Cutaneous  tubercular  re- 
action positive.     Frequent  temperature  over  37°  C. 

Gastric  contents  (after  tea  and  roll  breakfast)  March  18th:  Total 
acidity,  4%  ;  Mo  N.  Na  OH.  Free  HCl  is  absent.  No  food  residue 
from  the  previous  day.  Abundance  of  lactic-acid  bacilli,  partly  devel- 
oped into  verv  long  threads.      No  sarcinae. 

March  27th:  Total  acidity,  6%;  Mo  N.  Na  OH.  No  food  residue; 
sporadic  rod-shapes  reminding  one  of  leptothrix  buccalis. 

Stool:  Presents  almost  constantly  a  pure  culture  of  typical,  partly 
very  long  lactic-acid  bacilli.  Fairly  abundant  soap  needles  (after  moder- 
ate intake  of  fat!).      Blood-coloring  material  in  very  small  quantity. 


248  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Blood:  Ugh.,  90-100%;  leucocytes,  15,000. 
ad  8, — First  symptoms :  January,  1909. 
Status  presens:  March  20,  1910. 
Operation :  April  5,  1910. 
Duration :  About  1  year,  3  months, 
ad  9. — Operation  (Primarius  Dr.  Fr.  Schopf)  :  Extensive  carcino- 
matous infiltration,  particularly  of  the  posterior  surface  of  the  stomach, 
originating  in  the  lesser  curvature,  with  a  suggestion  of  an  hour-glass 
stomach.     Gastro-cnterostomy. 

Epicrisis:  The  chief  interest  in  this  case  lies  in  the  comparison  be- 
tween the  gastric  and  intestinal  bacteriological  findings. 

Whilst  the  feces  remaining  constantly  the  same  and  showing  at  every 
examination  abundant  presence  of  typical  lactic-acid  bacilli  made  one 
think,  in  the  first  place,  of  the  existence  of  a  gastric  cancer,  the  stomach 
contents  showed  a  changeable  finding. 

At  the  first  examination  a  typical  bacteriological  finding:  abundant 
lactic-acid  bacilli,  among  them  many  giant  forms. 

At  the  second  examination  only  a  few  rod-shapes  but  little  character- 
istic as  to  their  morphological  details. 

This  case  speaks  for  the  greater  constancy  of  the  fecal  vegetative 
findings  as  compared  to  the  gastric  flora,  which  latter  may,  under  circum- 
stances, be  subject  to  considerable  variations,  corresponding  probably  to 
the  varying  degree  of  stagnation. 

It  is  worthy  of  note  that  neither  at  tlie  first  nor  second  examination 
was  there  any  food  residue  from  the  previous  day ;  nor  were  there  any 
indications  of  a  pyloric  stenosis  (no  peristalsis,  no  dilatation,  never  any 
vomiting) . 

No  tumor  could  be  felt  corresponding  to  the  extension  of  the  cancer 
along  the  surface. 

Here,  in  addition  to  the  finding  of  decided  hypoacidity,  the  presence 
of  an  abundant  vegetation  of  lactic-acid  bacilli  in  the  stomach  contents 
and  especially  in  the  feces  formed  an  integral  part  of  the  diagnostic  cal- 
culation. 

Furthermore  worthy  of  note  were  the  continued  anorexia,  cramps  dur- 
ing the  period  in  which  the  stomach  was  emptying  itself  (about  2  hours 
after  eating),  and  sour  eructation. 

The  blood  showed  a  leucocytosis  of  15,000. 

The  very  pronounced  arcus  senilis  (early  senility?)  in  a  man  onl}'  45 
years  of  age  was  remarkable. 

Case  88.— J,  H.,  64  years,  M. 

ad  3. — No  infectious  diseases. 

ad  6. — Began  with  pain  in  the  stomach,  vomiting  and  diarrhea  ; 
now  and  then  night-sweats.      Epigastrium  sensitive  to  pressvire. 

ad  7. — A  resistance  of  cartilaginous  hardness,  the  size  of  a  walnut, 
in  the  pyloric  region.  Distinct  gastric  peristalsis.  Loud  systolic  mur- 
mur over  tlic  aortic  valve.      Pulse  50. 


CARCINOMA    OF    THE    STOMACH  249 

ad  9. — Autopsy  (Professor  Dr.  Fr.  Schlagenhaufer)  March  15, 
1908:  Infiltrating  fibrous  carcinoma  of  the  pyloric  region  with  stenosis. 
Aortic  insufficiency  and  stenosis. 

E.picrisis:  Night-sweats  occasionally  appear  as  an  early  s^^mptom  of 
malignant  diseases ;  the  bradycardia  existing  in  this  case  permitted  from 
the  start  the  exclusion  of  a  progressive  tubercular  process  as  the  cause  of 
the  night-sweats. 

Case  89.— R.  H.,  30  years,  F.  ' 

ad  1. — Parents  are  living  and  well,  so,  also,  brothers  and  sisters, 
ad  3.— No  I.  D.  C. 

ad  6. — Since  June,  1906,  increasing  pallor  and  loss  of  appetite 
especially  for  meat.  Since  June,  1907,  there  is  a  hard,  painless  swelling 
underneath  the  left  costal  arch.  Bowels  mostly  constipated;  frequent 
eructation  of  bile.  Of  late  frequent  colicky  pain  underneath  the  left  cos- 
tal arch  and  around  the  umbilicus,  said  to  be  independent  of  intake  of 
food.     Lumbar  pains. 

ad  T. — In  the  epigastrium  on  the  left  side  a  tough,  hard  tumor- 
mass,  distinctly  movable  with  respiration.  Soft  glands  in  the  left  su- 
praclavicular fossa.     No  symptom  of  pyloric  stenosis. 

Pigment  anomalies   of  the  skin,  hyperpigmented  areas   alongside   of 
non-pigmented  ones.     At  the  waistline  where  the  skirts  are  fastened  there 
is   a  girdle-like   depigmented  broad   stripe   encircling  the  trunk.      Mild 
edema  of  the  eyelids.     Irregular  slight  increases  in  temperature. 
Feces:  Abundant  vibrios. 
Blood:  Hgb.,  20%. 

ad  8. — Beginning:  June,  1906. 

Status  presens :  June  1,  1908. 
Autopsy:  June  15,  1908. 
Duration :  2  j^ears. 
ad  9. — Autopsy   (Pros.   Professor  Dr.  Fr.  Schlagenhaufer)  :  Ex- 
tensive, ulcerous  disintegrating  carcinoma  of  the  pyloric  region   of  the 
stomach,  enormously  extensive  glandular  metastases  retroperitoneally,  in 
the  posterior  mediastinum   and   also   in   the   region   of  the  thymus ;   the 
supraclavicular  glands  on  both  sides  have  undergone  necrotic  softening. 
Severe  anemia. 

Epicrisis:  An  early  cancer  at  the  age  of  30,  being  according  to  rule 
with  regard  to  its  duration  (two  years). 

The  pigmentary  anomalies,  arranged  in  segments,  found  also  in  perni- 
cious anemias,  deserve  attention  as  signs  of  an  abnormal  constitution. 
Virchow's  glands  in  this  case  are  of  exceptionally  soft,  medullary  con- 
sistence. The  glandular  metastases,  the  liver  remaining  entirely  free, 
is  remarkable. 

The  feces  exhibit  a  well-developed  growth  of  vibrio  which  is  foreign  to 
a  normal  stool. 

The  edema  of  the  eyelids  may  in  part  be  due  to  the  formation  of 
metastases  in  the  mediastinal  glands. 


250  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  90.— A.  A.,  76  years,  F. 

ad   1. — Parents  were  healthy,  died  at  a  very  old  age  (over  80). 

ad  3. — Measles ;  otherwise  no  I.  D,  C. 

ad  5. — Always  was  healthy ;  inflammation  of  varicose  veins  at  25. 

ad  6. — Since  July,  1908,  after  meals  vomiting  and  foul  smelling 
eructation ;  disgust  for  food.  Diarrhea  alternating  with  constipation. 
For  the  past  2  years  treated  for  floating  kidney   (.''). 

ad  7. — Extensive,  hard  tumor-mass  at  about  the  level  of  the  umbili- 
cus, movable  in  all  directions,  except  that  the  downward  movability  is 
limited.      Vomitus  contains  intestinal  flora. 

ad  8. — Beginning:  July,  1908. 

Status  presens :  September  27,  1908. 
Autopsy:  September  28,  1908. 
Duration :  2  months. 

ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Car- 
cinoma, about  the  size  of  a  man's  fist,  originating  in  the  lesser  curvature 
of  the  stomach,  put rif active. 

Epicrisis :  One  is  inclined  to  suspect  that  the  supposedly  floating  kid- 
ney for  which  this  76-year-old  patient  was  treated  for  two  years  was 
identical  with  the  gastric  tumor  which  remained  movable  up  to  the  last. 
Decomposition  of  gastric  cancer  is  not  of  very  frequent  occurrence.  It 
is  necessary,  however,  to  recognize  this  possibility,  as  otherwise  in  case  of 
fecal  vomiting  accompanied  by  intestinal  flora  one  may  in  similar  cases 
be  misled  into  thinking  of  intestinal  processes  (bowel  stenosis,  etc.)  or  at 
least  assuming  a  gastro-colonic  fistula. 

Case  91. — J.  S.,  61  years,  M.    Wood  turner. 

ad  1. — Father  died  at  45  from  pulmonary  hemorrhage,  mother  died 
of  old  age ;  3  brothers  and  sisters  are  well. 

ad  2. — Hair  turned  gray  onl}'  during  last  10  years,  formerly  had 
black  hair  like  the  other  members  of  the  family.      No  rheumatism. 

ad  3.— No  I.  D.  C.     No  lues. 

ad  4. — Never  had  stomach  pain ;  could  eat  very  fat  foods ;  bowels 
always  regular. 

ad  5. — No  alcohol,  no  tobacco;  was  always  perfectly  healthy;  the 
present  disease  is  his  first. 

ad  6. — Constipation  since  October,  1908.  In  the  summer  of  1909 
those  around  him  noticed  his  pale  appearance.  In  July,  1909,  continuous 
feeling  of  cold.  Coughing  began ;  the  appetite  became  bad.  Intolerance 
toward  meat.  Immediately  after  eating  meat  abdominal  cramps  lasting 
two  hours.  Emaciation  only  during  the  last  weeks.  No  vomiting  up  to 
the  end,  frequent  einictation,  great  thirst, 

ad  7.- — A  transverse  cylindrical  tumor-mass  in  the  epigastrium, 
somewhat  to  the  left  and  above  the  level  of  the  umbilicus ;  tenderness  to 
pressure  at  that  place.  Yellowish  coloration  of  the  face  (no  jaundice). 
No  edemas  (October  30,  1909)  ;  severe  edema  (December  1,  1909).  Pos- 
teriorly on  the  right  side  below  a  pleural  effusion  measuring  the  width  of 


CARCINOMA    OF    THE    STOMACH  'Jol 

a  h.uul  (slightly  licinorrhugic).     Pulse  120  (36°  C.)-     No  angiomas  on 
the  skin.     Frequent  temperature  of  38°  C. 

Stool:  Constant  presence  of  abundant  blood-coloring  matter;  no  lac- 
tic-acid bacilli. 

Urine:  No  diazo  reaction;  aldehyde  reaction  absent  in  the  beginning, 
later  continuously  strongly  positive.     Indican  reaction  negative. 

Blood:  Hgb.  60-70%  (October  30,  1909). 
ad  8. — Beginning:  October,  1908. 

Observation :  October-December,  1909. 
Autopsy:  December,  1909. 
Duration :  About  1  year,  2  months, 
ad  9. — Autopsy    (Pros.   Professor  Dr.   Fr.   Schlagenhaufer)  :  Ul- 
cerating medullary  carcinoma  of  the  pyloric  region  of  the  stomach,  non- 
stenosing.     Right-sided  fibrinous  hemorrhagic  pleuritis.     A  gangrenous 
area  about  the  size  of  a  fist  in  the  left  upper  lobe  (aspergillosis!).--      No 
metastases  in  the  liver  nor  at  the  porta  hcpatis. 

Epicrisis:  A  pyloric  carcinoma  running  its  course  without  vomiting! 
In  contradistinction  to  the  fibrous  forms,  medullary  cancers  of  the  stom- 
ach, rarely  constricting  because  of  severe  ulceration,  yield  but  few  local 
symptoms  (anemia,  edemas,  cachexia)  appear  very  prominently.  A  yd- 
lowish  discoloration  of  the  face  is  peculiar,  especially  to  the  medullary 
forms  of  gastric  cancer.  Constipation  was  the  very  first  symptom.  Pro- 
nounced elimination  of  urobilinogen  in  connection  with  gastric  cancer  is 
not  an  absolutely  certain  criterion  of  formation  of  metastasis  in  the  liver 
or  ad  portam  hepatis.      It  must,  however,  cause  one  to  think  of  same. 

Ohfrmeyer's  indican  reaction  was  negative  (pancreas  normal). 

The  right-sided  moderate  hemorrhagic  pleural  effusion  was  due  to 
tuberculosis;  the  area  of  disintegration  in  the  left  upper  lobe  (contents 
odorless)   owes  its  origin  to  an  aspergillus  invasion. 

Case  92. — A.  S.,  54  years,  M. 

ad  1. — Father  and  mother  died  of  some  stomach  disease. 

ad  3. — Had  pneumonia  once;  no  I.  D.  C. 

ad  6. — In  March,  1908,  beginning  of  stomach  trouble;  the  patient 
could  not  eat  anything,  had  to  vomit  everything;  with  it  there  was  eruc- 
tation without  bad  taste.  In  August,  1908,  was  operated  on  for  sus- 
pected rectal  cancer;  a  general  carcinomatosis  of  the  peritoneum  was 
found  to  be  present.  It  is  said  that  at  that  time  there  was  obstipation, 
often  lasting  8  days,  frequent  foul-smelling,  even  fecal  vomiting. 

ad  7. — Tensely  elastic  abdomen  with  intestinal  peristalsis  and  loud 
rumbling.  Rectum :  At  the  anterior  circumference  a  semicircular,  bonj-- 
hard  mass  of  infiltration  covered  bv  mucous  membrane. 


'*  In  the  cavity  in  the  Innjr  there  is  peculiar  network,  ajiparently  made  up  of  hlood- 
vessels,  the  trabeculae  beinp:  substituted  by  a  mortar-like  mass;  contents  have  no  bad 
odor.  These  mortar-like  masses  consist  of  a  thick  weaving  of  mycelia.  Histologicallv, 
the  pleura  is  found  to  be  tubercular. 


252  TU.AIORS    OF    THE    ABDOMINAL    VISCERA 

Feces :  Very  light  colored,  containing  much  neutral  fat  and  fatty  acid 
needles. 

ad  8. — Beginning:  March,  1908. 

Status  prcsens:  October  1,  1908. 
Autopsy:  October  11,  1908. 
Duration:  About  7  months, 
ad  9. — Autopsy    (Pros.   Professor  Dr.   Fr.  ScJilagenhaufer)  :    In- 
filtrating carcinoma  of  the  stomach  and  general  carcinosis  of  the  peri- 
toneum ;  stenosis  of  the  ileum.     Ileus.     Metastases  about  the  rectum ;  dis- 
tention of  the  large  gut. 

Epicrisis:  Father  and  mother  had  also  died  of  gastric  cancer. 
During  the  latter  course  manifestations  of  intestinal  constriction  oc- 
cupied the  foreground  (intestinal  peristalsis,  fecal  vomiting,  severe  con- 
stipation), so  that,  as  the  history  states,  in  view  of  a  tumor-mass  which 
could  be  felt  through  the  rectum  the  false  diagnosis  of  a  rectal  cancer  was 
made.  Of  late  there  were  present  fat-containing  stools  which,  for  lack 
of  a  corresponding  finding  in  the  liver  or  pancreas,  must  be  considered 
as  of  intestinal  origin  (disturbed  absorption). 

Case  93.— J.  G.,  61  years,  F. 

ad  1. — Father  died  of  pulmonary  catarrh. 

ad  3. — Measles  at  6;  typhoid  at  11;  had  pneumonia  once. 

ad  4. — Formerly  had  so  good  a  stomach  that  she  "could  have  eaten 
pebbles." 

ad  6. — For  the  past  four  years  has  had  stomach  trouble:  vomiting 
and  extremely  foul-smelling  eructation.  Constipation.  Lost  over  20  kg 
in  weight  during  one  year. 

ad  7. — Daily  vomiting  of  "coffee-grounds,"  containing  sarcinas. 

ad  8.— Autopsy:   November   10,   1908. 

ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  ScJilagenhaufer)  :  Cir- 
cular constricting  carcinoma  of  tlie  pylorus  with  great  dilatation  of  the 
stomach  and  consequent  dystopia  of  the  pylorus  (pylorus  on  a  level  with 
the  bifurcation  of  the  abdominal  aorta). 

Epicrisis:  The  drastic  expression  with  which  this  patient  characterizes 
her  former  digestive  power,  "I  could  have  eaten  pcbV)les,"  recurs  fre- 
quently in  the  statements  of  patients  suffering  from  cancer  of  the  stom- 
ach. As  already  emphasized,  it  seems  that  "stomach  athletes"  are  more 
disposed  to  gastric  cancer  than  stomach  weaklings.  Foul  smelling  eruc- 
tation always  deserves  very  earnest  attention. 

Case  94.— F.  S.,  61  years,  M. 
ad  3.— No  I.  D.  C. 

ad  6. — Pale  face  color  for  the  past  year ;  for  the  past  7  weeks 
even  the  smallest  spoonful  of  soup  is  vomited.  Constipation  since  the 
beginning  of  the  disease. 

ad  7. — Ascites.  On  the  left  side  underneath  the  costal  arch  a  tumor- 
mass  can  be  felt.    (Autopsy:  Omentum  thrown  back  over  the  upper  surface 


CARCINOxAIA    OF    THE    STOMACH  253 

of  the  liver.)      The  patient  vomits  fetid  pus,  containing  lactic-acid  bacilli 
of  enormous  length,  besides  colon  bacilli, 
ad  8.- — Beginning:  December,   1907. 

Status  presens :  December  7,  1908. 

Autopsy:  December  10,  1908. 

Duration:  About  1  year, 
ad  9. — Autopsy  (Pros,  Professor  Dr.  Fr.  Schlagenhaufer)  :  Con- 
stricting carcinoma  of  the  pylorus,  ulcerating  very  much;  few  scattered 
metastases  in  a  cirrhotic  liver.  Omentum  infiltrated  in  toto  and  thrown 
back  on  the  upper  surface  of  the  liver.  Abscess  in  the  left  upper  lobe  of 
the  lung. 

Epicrisis:  Increasing  pallor  of  the  face  counts  among  the  early  symp- 
toms of  carcinoma.  It  may  be  due  to  diminished  hemoglobin  content 
(hemorrhage!),  but  it  may  also  be  that  there  enters  into  consideration, 
as  a  causative  factor,  a  decrease  in  the  force  of  the  circulation  due  to 
cachexia,  analogous  to  the  acute  pallor  in  transient  indispositions  of 
fainting  spells.  Vomiting  of  macroscopically  recognizable  pus  belongs 
to  exceedingly  rare  findings  in  gastric  cancer;  the  pus  flora  ("giant 
forms"  of  lactic-acid  bacilli)  in  this  case  were  of  value  for  a  rapid  diag- 
nosis. 

The  tumor  that  could  be  felt  corresponding  to  the  omentum  thrown 
back  on  the  upper  surface  of  the  liver. 

Case  95.— M.  H.,  36  years,  F. 

ad  6. — Cough  since  November  2,  1908;  appetite  became  less,  fre- 
quent nausea,  now  and  then  vomiting.  Three  weeks  ago  a  feverish  feeling 
(chilliness),  rather  severe  coughing  and  stabbing  in  the  left  chest  and 
back,  especiall}^  on  breathing.  No  expectoration  ;  of  late  no  feverishness. 
ad  7. — A  well-nourished  individual  with  a  somewhat  pastj^  coun- 
tenance, pale  facial  color,  slightly  cyanotic.  Temperature,  mostly  36°  C» 
Pulse,  114-126.  Very  great  dyspnea  and  tachypnea  with  extreme  air 
hunger.  For  want  of  breath  the  patient  cannot  lie  down,  but  must  sit 
up.  Pain  on  pressure  over  the  base  of  the  left  lung  and  in  the  axillary 
portions ;  there  was  also  dulness  over  an  area  about  the  width  of  a  hand, 
and  bronchial  breathing;  on  the  right  shai*p  vesicular  breathing,  with 
here  and  there  an  indication  of  crepitation.  In  the  left  supraclavicular 
space  small,  soft  glands,  the  size  of  a  bean.  Cardiac  findings  normaL 
Aspiration  on  left  side  posteriorly  below:  Hemorrhagic  eflFusion,  con- 
taining remarkably  large  cells  with  nuclei  rich  in  chromatin  and  large 
cell-conglomerations,  much  variegated  forms. 
Gram  stain:    Diplococci. 

ad  8. — Beginning:  About  November  15,  1908. 
Status  presens:  January  15,  1909. 
Autopsy:  January  20,  1909. 
Duration:  About  2  months, 
ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Mili- 
ary, lymphogenous   carcinomatosis  of  both  lungs   (macroscopic   appear- 
ance reminding  of  miliary  tuberculosis),  originating  from  a  small  ulcer-like 


254  TUMORS    OF    THE    ABDOMINAL    VISCERA 

carcinoma  of  the  stomach.  In  fresh  sections  of  the  lung  one  can  see 
innumerable  grayish-white  nodules,  from  the  smallest  size  to  that  of  a 
lentil,  which  are  united  by  extremely  fine  threads.  This  diffuse  infiltra- 
tion of  the  pulmonary  tissue  can  also  be  made  out  very  distinctly  with 
the  fingers.  The  lymphatic  channels  of  the  pleune  are  filled  with  can- 
cerous masses ;  in  the  left  pleural  cavity  there  is  a  hemorrhagic  effusion. 

Epicrisis:  As  a  result  of  the  peculiar  miliary  formation  of  metastases 
in  the  lungs  the  gastric  cancer  in  this  case  ran  its  course  in  a  way  that 
would  remind  one  of  miliary  tuberculosis.-"^ 

The  following  points  were  decisive  in  making  during  life  the  diagnosis 
of  "miliary  carcinomatosis  of  the  lungs":  The  extreme  dyspnea  (cardiac 
findings  normal  and  no  other  etiology  present)  could  by  exclusion  be 
interpreted  only  as  pulmonary. 

Against  miliary  tuberculosis:  afebrile  course,  absence  of  diazo  reac- 
tion. Aside  from  the  small  pleural  effusion  no  objective  pulmonary  find- 
ing and  yet  maximal  disturbance  in  function !  This  contrast  reminded 
one  of  the  similar  behavior  in  miliary  tuberculosis.  The  microscopical 
finding  in  the  hemorrhagic  fluid  obtained  by  aspiration  was  highly  sug- 
gestive of  malignant  disease.  It  is  true  there  were  Gram  staining  diplo- 
cocci  present,  but  this  was  explained  by  way  of  an  intercurrent  infection. 
The  finding  of  glands  in  the  left  supraclavicular  fossa  confirmed  the  as- 
sumption of  a  malignant  process.  All  this  taken  together  led  to  the  diag- 
nosis of  a  "miliary  carcinomatosis  of  the  lungs"  which  was  actually  veri- 
fied at  autopsy. 

Case  96.— N.  N.,  60  years,  F. 

ad  4. — Stomach  ailments  for  the  past  four  years ;  there  were  present 
exquisite  "hunger  pains"  of  a  burning  character,  spreading  also  over  the 
lower  portion  of  the  sternum.  The  pain  ceased  immediately  after  drink- 
ing milk,  so  also  after  dinner,  but  recurred  after  two  hours.  No  tender- 
ness on  pressure.      Slight  improvement  at  Karlsbad. 

ad  6. — For  the  past  half  year  there  is  no  longer  any  "hunger 
pain" ;  not  even  when  the  patient  goes  without  food  all  day  are  there  any 
pains.  Milk  is  poorly  tolerated,  causes  sour  burning  and  belching  of 
gas ;  often  gurgling  noises  along  the  esophagus.  Solid  foods,  such  as 
ham  sandwich  with  caviar,  are  better  tolerated  than  liquids.  Ham  eaten 
at  night  is  at  times  vomited  the  next  morning.  During  the  last  half 
year  has  lost  20  kg  in  weight. 

ad  T. — Transversely  running,  very  firm  cylindrical  tumor  under- 
neath the  xiphoid  process,  ascending  and  descending  with  respiration. 
No  splashing;  no  peristalsis. 

After  test-hreakfast:  HCl  absent,  pepsin  absent;  flora:  lactic  acid  and 
colon  bacilli. 

ad  8. — Beginning:  Middle  of  April. 

Status  presens:  October  10,  1904. 
Operation :  Short  time  after. 

"  See  H.  Ifippman.  Uber  einen  Fall  von  akuter  hamatogen.  Carcinosis.  Zeitschr. 
f.  Krebsforschung,  1905,  page  290. 


rARCINOMA    OF    THE    STOMACH  255 

ad  9. — OporHtion :  Extensive  gastric  cancer  necessitating  almost 
total  resection  of  the  stomach.      Relapse  after  one  year. 

Epicrisis:  The  appearance  of  the  cancer  in  this  instance  is  marked 
by  the  cessation  of  pain. 

During  the  benigni  stage  of  the  disease,  which  was  probably  an  ulcer, 
hunger  promptly  elicited  pain  which  was  cut  short  by  the  ingestion  of 
milk  (neutralization  of  HCl  in  the  gastric  juice!). 

As  the  cancer  l)rought  about  the  permanent  cessation  of  HCl  secretion 
it  led  to  permanent  disappearance  of  the  "hunger  pain."  Pronounced 
eructation  of  air  with  gurgling  noises  along  the  gullet,  as  met  with  in  this 
case,  may  easily  mislead,  and  particularly  when  other  neuropathic  stig- 
mata are  at  hand  ma}-  cause  one  to  think  of  functional  gastric  disturbance 
(aerophagy,  etc.). 

Case  97.— N.  N.,  60  years,  M.     Capuchin. 

ad  4. — Formerly  could  tolerate  ever3^thing  well. 

ad  6. — For  the  past  year  anorexia,  intolerance  toward  meat,  con- 
stipation. 

ad  7. — P'xtreme,  pulsating  tumor-mass  underneath  the  left  costal 
arch.      Pale  yellowish  color  of  the  face.      Continuous  salivation. 

ad  8. — Beginning:  January,  1905. 

Status  presens:  January  8,  1906. 
Epicrisis:  The  continuous  salivation  deserves  mention  as  an  unusual 
symptom. 

Case  98.— H.  E.,  38  years,  F. 

ad   1. — Father  died  of  epilepsy. 

ad  3. — As  a  child  had  measles;  at  11  had  malaria. 

ad  5. — Six  confinements,  last  one  in  summer  of  1901. 

ad  6. — About  Christmas,  1901,  the  patient  noticed  an  enlargement 
of  her  abdomen ;  preceding  that  there  had  been  night-sweats  affecting 
particularly  the  head,  and  frequent  vomiting  of  food  immediately  after 
eating.  The  enlargement  of  the  abdomen  ran  along  without  pain.  In 
March,  1902,  first  appearance  of  sensitiveness  to  pressure  in  the  left 
lower  quadrant.  Severe  constipation,  intervals  between  movements  up  to 
eight  days.  The  patient  claims  to  have  noticed  a  swelling  synchronous 
with  pain  in  the  left  side  on  a  level  w'ith  the  umbilicus ;  this  swelling  soon 
disappeared.      Great  emaciation. 

ad  7. — Yellowish  pale  coloration  of  the  face.  Ascites  of  moderate 
degree,  bilateral  hydrothorax,  especially  on  the  right.  Temperature  ele- 
vations up  to  37.8°  C.  Hard  tumor-masses  can  be  felt  per  vaginam, 
especially  through  its  posterior  wall.  Rectum  somewhat  narrowed  an- 
teriorly. 

Blood:  2,800,000  erythrocj^tes,  8,000  leucocytes,  30%  hemoglobin. 
Urine:  Indican  and  urobilinogen  very  abundant. 

ad  8. — Status  presens:  End  of  March,  1902. 
Autopsy:  April  12,  1902. 


256  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  9. — Autopsy  (Professor  Dr.  H.  Albrecht)  :  Carcinoma  of  the 
pylorus  superimposed  on  a  chronic  round  ulcer,  with  moderate  stenosis 
of  the  pylorus.  Secondary  colloid  carcinoma  of  the  great  omentum,  the 
parietal  peritoneum,  the  entire  peritoneum  in  the  pouch  of  Douglas  with 
infiltration  of  the  urinary  bladder,  parametrium  and  both  ovaries. 
Secondary  carcinoma  of  the  right  costal  pleura.  Bilateral  chylous  hydro- 
thorax. 

Epicrisis:  This  38-year-old  patient  had  been  referred  to  the  clinic 
with  the  diagnosis  "tuberculosis  peritonei."  The  history  brought  out  the 
fact  of  night-sweats,  there  Avas  ascites  and  a  right-sided  pleural  effusion, 
the  course  of  the  disease  being  afebrile.  But  the  facial  color  itself  spoke 
against  the  assumption  of  a  tubercular  disease  of  the  peritoneum.  There 
was  present  a  pronounced  "yellowish"  discoloration  ("teint  paille  jaune"). 
Furthermore,  the  pleural  effusion  was  easily  movable.  Hard  tumor-masses 
could  be  felt  through  the  vagina. 

The  case  illustrated  the  "peritoneal-pleural"  type  of  gastric  cancer 
and  is  remarkable  because  of  the  prominence  of  the  gynecological  findings. 

Case  99.— N.  N.,  50  years,  M. 

ad  2. — In  June,  1904,  inflammation  of  the  shoulder- joint  and  at 
the  same  time  an  inflamed  condition  in  the  large  toe-joint.  Cure  in 
Pystian. 

ad  4. — Stomach  always  in  order;  could  eat  fat  and  sour  foods 
without  trouble. 

ad  6. — In  February,  1906,  sudden  occurrence  of  stomach  troubles, 
rapidly  growing  worse,  so  that  at  present  only  a  little  tea  and  kephir  is 
tolerated.  Stooping  easily  induces  vomiting  of  watery-salty  masses. 
Constipation  since  February,  1906.  A  short  time  after  eating  a  feeling 
of  pressure  in  the  epigastrium  and  underneath  the  left  costal  arch.  Very 
soft  eggs  are  well  borne.  Very  severe  burning  after  taking  hydrochloric 
acid  solution. 

ad  7. — A  tumor  of  the  pylorus,  the  size  of  a  child's  fist,  movable 
especially  toward  the  left.  Blood-vessels  rigid,  slight  insufficiency  of  the 
aortic  valves. 

ad  8. — Beginning:  February,  1906. 

Status  presens:  June  28,  1906. 
Epicrisis:  Uratic  diathesis  with  an  attack  of  gout  about  a  year  and 
a  half  prior  to  the  appearance  of  the  first  symptoms  of  cancer.     "Ex- 
pressible" stomach  with  regurgitation  on  stooping. 

Case  100. — M.  D.,  69  years,  M.    Gardener's  assistant. 

ad  6. — Since  October,  1908,  attacks  of  colic-like  pains  in  the  ab- 
domen, occasionally  accompanied  by  vomiting.  Since  November,  1908, 
decided  emaciation.  Even  during  his  stay  at  the  hospital  (February, 
1909)  appetite  was  good  at  the  start;  plentiful  ingestion  of  food. 

ad  7. — An  irregular,  firm,  small  tumor-mass  in  the  epigastrium. 
Hard,  i-ound  tumors  in  the  region  of  the  sigmoid  flexure ;  these  later  dis- 


CARCINOMA    OF    THE    STO:\IACH  257 

appeared  and  the  flexure  could  be  felt  as  a  contracted  cord.  On  and  off, 
feeble  appearance  of  small  intestinal  loops,  especially  in  the  ileocecal  re- 
gion. Hernia  in  the  linea  alba.  Pale,  cachectic  face  color.  Pulsating 
carotids.      No  edemas ;  temperature   often  36°   C. 

Urine:  Indican  not  increased;  no  aldehyde  or  diazo  reaction. 
Stool:  Blood-test  constantly  positive, 
ad  8. — Beginning:  October,  1908. 

Status  presens:  February  24,  1909. 
Autopsy:  April  22,  1909. 
Duration:  About  7  months, 
ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Med- 
ullary carcinoma  of  the  stomach-wall  in  the  region  of  the  lesser  curva- 
ture, with  severe  constriction  at  the  pylorus.      Very  small  metastases  in 
the  liver  and  the  pleura.      Slight  atheroma  of  the  aorta. 

Epicrisis:  The  objective  examination  of  this  deaf  and  dumb  patient 
yielded  as  the  first  finding  hard  tumors  in  the  region  of  the  sigmoid  flex- 
ure, which  were  soon  diagnosed  as  fecal  accumulations.  In  and  of 
itself  rare,  this  finding  is  occasionally  met  with  in  gastric  cancers  as  an 
indication  of  severe  constipation ;  thus  in  this  case  it  gave  the  first  occa- 
sion for  thinking  of  a  gastric  cancer. 

Visible  bowel  peristalsis  as  described  above  (small  loops  of  intestine, 
moderate  rigidity)  is,  as  already  repeatedly  emphasized,  not  at  all  a  rare 
finding  in  connection  with  pyloric  constrictions.^^ 

Case  101.— N.  N.,  60  years,  M. 

ad  4. — Always  has  had  a  sensitive  stomach.  Since  May,  1905, 
pain  two  hours  after  dinner,  one  hour  after  breakfast;  often  also  on  a 
fasting  stomach,  in  which  latter  case  the  ingestion  of  milk  affords  imme- 
diate relief. 

ad  6. — Since  December,  1906,  disgust  toward  meat,  constipation. 
Since  February,  1907,  complete  anorexia.  Even  two  years  ago  there  was 
found  great  hypoacidity.  The  severe  pains  existing  formerly  have 
ceased,  but  painful  sensations  are  still  present  in  the  epigastrium  and  be- 
tween the  shoulder-blades,  somewhat  more  on  the  left  side.  Frequent 
eructation  of  gas. 

ad  7. — Moderately  firm   resistance  in  the  epigastrium,   about   the 
size  of  a  walnut,  resting  on  the  aorta,  felt  best  in  the  dorsal  position. 
Stool:  Chemical  blood-test  constantly  positive. 
August,  1907:  Uncontrollable  hematemesis  and  death, 
ad  8. — Beginning:  December,  1906. 

Status  presens :  May  13,  1907. 
Existus:  August,  1907. 
Duration :  About  9  months. 
Epicrisis:  As   in  Case  96,  so  also  here,  there  was  present   "hunger 
pain,"  which  could  be  aborted  by  the  use  of  milk. 

="03868  11,  14,  36,  39. 


258  TUMORS    OF    THE    ABDOMINAL    VISCERA 

During  the  further  course,  probably  througli  the  cessation  of  HCl 
secretion,  this  symptom  disappears. 

This  may  have  been  a  case  of  a  carcinomatous  ulcer. 

Case  102.— N.  N.,  60  years,  M. 

ad  4>. — Stomach  trouble  for  the  past  fourteen  years  ;  before  that 
was  in  the  habit  of  always  eating  rapidly  and  hot  foods.  Often  pain 
three  hours  after  eating,  excitement  aggravated  the  complaints.  A  ner- 
vous stomach  disease  was  diagnosed.  Withdrawal  of  stomach  contents 
some  years  ago  showed  normal  secretory  findings. 

ad  6. — In  1906  there  was  found  a  deficiency  of  HCl.  In  April, 
1907,  severe  hematemesis.  Frequent  eructation  and  vomiting  of  sour 
masses ;  often  pressure  in  the  stomach  and  hiccough.  Appetite  slight, 
but  even  meat  can  be  eaten. 

ad  7. — Resistance  and  tenderness  to  pressure  in  the  region  of  the 
pylorus. 

ad  8. — Beginning:  1906. 

Status  presens :  September  7,  1907. 
Exitus:  October  1,  1907. 
Epicrisis:  The  "nervous"  stomach  ailment  may  have  been  an  ulcer, 
and  the  final  disease  a  carcinomatous  ulcer. 

Case  103.— J.  K.,  46  years,  M.    Locksmith. 

ad   1. — One  sister  died  of  gastric  cancer. 

ad  3. — As  a  child  had  "miliary  fever";  in  1869  had  typhoid,  being 
sick  for  three  months. 

ad   -1. — Never  had  stomach  trouble;  bowels  always  regular. 

ad  6. — About  August,  1900,  the  patient  frequently  experienced  a 
kind  of  "hungr}^  feeling"  in  the  stomach,  but  there  was  no  appetite.  Great 
feeling  of  thirst  set  in. 

Later  sour  eructation,  especially  at  night.  In  June,  1901,  there  were 
added,  sick  feeling  after  eating,  pressing,  and  now  and  then  colicky  pain 
in  the  epigastrium.  Felt  good  when  the  stomach  was  empty.  Every 
lateral  position  was  badly  tolerated.  In  August,  1901,  the  patient  had 
lost  all  appetite,  vomiting  occasionally  up  to  two  litres.  His  weight 
dropped  from  65  to  46  kg.  On  November  15,  1901,  hematemesis  ("about 
two  litres  of  blood").  Gastro-cnterostomy  performed  on  November  22, 
1901.  Subsequent  gain  in  weight  and  perfectly  free  from  complaints 
until  April,  1902.  Decrease  of  appetite,  meat  intolerance,  pain  in  the 
middle  line  of  the  epigastrium,  about  one  hour  after  eating. 

ad  7. — Since  July  4,  1902,  swelling  of  the  left  arm  and  the  left  side 
of  the  neck;  supraclavicular  pain  on  the  left  side,  in  the  left  upper  arm 
especially  along  the  course  of  the  brachial  artery ;  pressing  pains  also 
in  the  neck,  on  the  left  side,  extending  over  the  left  half  of  the  occipital 
region.  Gradual  retrogression  of  the  objective  findings  and  the  sub- 
jective complaints,  so  that  on  July  30,  1902,  there  was  neither  swelling 
nor  painfulness. 


CARCINOMA    OF    THE    STOMACH  259 

ad  8. — Beginning:  August,  1900. 

Operation:  November  22,  1901. 
Status  prcsens:  July,  1902. 
Autopsy:  August  17,  1902, 
Duration :  About  2  years, 
ail  9. — Operation :   Tumor   at   the   pylorus   extending   toward   the 
fundus. 

Autopsii  (Professor  Dr.  H.  Albrecht)  :  Infiltrating  carcinoma  of  the 
pylorus  and  the  posterior  wall  of  the  stomach  with  constriction  of  high 
degree.  Secondary  carcinosis  of  the  peritoneum.  Hemorrhagic  ascites. 
Mural  thrombosis  in  the  thoracic  duct;  old  thrombosis  of  the  left  in- 
nominate vein  and  a  more  recent  tlirombosis  of  the  left  subclavian  and 
jugular  veins. 

Epicrisis:  The  initial  subjective  symptoms  were  sensations  of  hunger 
with  coexisting  anorexia.  Subsequently  the  typical  crescendo  of  re- 
gurgitation phenomena.  After  the  carcinoma  had  existed  for  one  year, 
there  occurred  profuse  hematemcsis. 

The  coincident  processes  of  thrombosis  in  the  thoracic  duct  and  the 
left  subclavian  and  jugular  veins  are  of  interest. 

Similarly  as  typical  metastases  in  the  left-sided  supraclavicular  glands 
occur  through  the  thoracic  duct,  the  thought  obtrudes  itself  whether  the 
thrombosis  of  the  left  subclavian  vein  was  not  brought  about  in  this  way. 
Accordingly  we  would  be  dealing  with  a  clinical  equivalent  of  "Virchow's 
glands."  The  thrombosis  in  the  left  innominate  vein  was  by  no  means 
due  to  compression  b}^  external  glands. 

Case  104. — K.  M.,  73  years,  M.    Assistant  lacemaker. 

ad  3.— No  I.  D.  C. 

ad   4. — Never  had  an}'  digestive  disturbances. 

ad  5. — Was  alwaj's  in  good  health. 

ad  6. — Since  Januar}',  1909,  irregular  bowel  movements,  at  times 
no  movement  for  three  days,  then  again,  three  movements  in  one  day.  Since 
this  time  now  and  then  cramps  even  at  night  in  the  lower  abdominal  region 
and  as  high  up  as  the  umbilicus  together  with  slight  distention  of  the 
belly.  Duration  one  to  two  hours.  Appetite  very  good,  "agreeable" 
eructation,  ingestion  of  food  has  no  appreciable  influence  on  the  pain. 
On  and  off  pain  after  bowel  movements. 

ad  7. — A  hard  tumor  about  the  size  of  a  nut,  in  the  region  of  the 
gall-bladder  and  to  the  left  of  it.  During  the  further  course  great  en- 
largement of  the  liver.  "Leather  creaking"  in  the  epigastrium  which  can 
also  be  felt.  Over  the  left  lobe  of  the  liver,  especially  at  the  end  of  ex- 
piration, a  loud,  blowing,  systolic  murmur  (normal  auscultatory  findings 
at  the  cardiac  apex).  During  the  last  days  of  life  this  murmur  disap- 
peared. Radial  artery  much  sclerosed.  No  edemas.  Dirty  pale  color 
of  the  face.  Vomiting  only  twice  during  the  course  of  the  disease.  Sahli's 
desmoid  reaction  negative. 

Stool:  No  indican  reaction  after  repeated  examinations.  Aldehyde 
reaction  distinctly  positive.     No  diazo  reaction. 


260  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  8. — Beginning:  January,  1909. 

Status  presens:  February  22,  1909. 
Autopsy:  July  5,  1909. 
Duration :  5  months, 
ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Nut- 
size,  deeply  ulcerating  carcinoma  of  the  greater  curvature,  situated  5  cm 
above  the  pylorus;  liver  metastases  very  numerous.      Ascites.      Chronic 
inflammation  of  the  splenic  capsule. 

Epicrisis:  Attacks  of  colic  and  bowel  irregularities  usher  in  the  disease, 
gastric  symptoms  associating  themselves  much  later. 

Even  at  a  time  when  the  palpatory  finding  in  the  epigastrium  was  yet 
obscure,  the  auscultatory  and  palpatory  finding  of  an  epigastric  friction 
noise  ("leather  creaking")  made  certain  the  diagnosis  of  a  process  going 
on  in  this  place.  During  the  further  course  there  appeared  over  the 
left  lobe  of  the  liver  a  systolic,  blowing  murmur,  which  disappeared  only 
a  few  days  before  death  (murmur  due  to  arterial  compression). 

The  face  color  was  dirty-gray,  not  showing  that  yellowish  tint  often 
peculiar  to  gastric  cancer.  Obermeijer's  indican  reaction  proved  con- 
stantly negative  after  repeated  examinations,  though  autopsy  did  not 
reveal  any  lesion  of  the  pancreas. 

Case  105.— N.  N.,  60  years,  M. 

ad  3. — Had  yellow  fever. 

ad  4. — Formerly  had  a  very  good  stomach. 

ad  6. — Beginning  in  July,  1908,  with  attacks  of  dizziness ;  since 
then  anorexia,  disinclination  toward  meat.  Often  very  foul-smelling 
"sweetish-rotten"  eructation,  after  which  the  patient  felt  somewhat  re- 
lieved ;  occasionally  pain  underneath  the  left  costal  arch,  e.g.,  after  eating 
grapes.  Oil  and  soda  bicarb,  yield  slight  improvement.  Gi'eat  tendency 
to  sleep.  During  the  night  sometimes  cramp-like  sensations  in  the  arms 
and  legs,  sweats.      Severe  emaciation  and  very  sensitive  to  cold. 

ad  7. — On  an  empty  stomach  with  right  lateral  position  nodular 
masses,  about  the  size  of  nuts,  can  be  felt  underneath  the  left  costal  arch. 
In  the  middle  line  the  pylorus  now  and  then  stiffens  into  a  hard  cord, 
about  as  thick  as  a  finger,  which  disappears  again  under  the  palpating 
fing-ers.  A  hard  ffland  in  the  left  axilla. 
Stool:  Abundant  lactic-acid  bacilli. 

ad  8. — Beginning:  June,  190.5. 

Status  presens:  September  14,  1908. 
Epicrisis:  Formation  of  metastases  in  the  glands  of  the  left  axilla 
belongs  to  the  very  rare  exceptions ;  the  same  is  true  of  conditions  of 
tetany  as  shown  in  this  case.  Spastic  conditions  set  in  at  the  pylorus,  so 
that  for  a  few  moments,  the  latter  can  be  felt  as  a  firm  cord,  at  the  same 
time  that  there  are  squirting  noises. 


Carcinoma  of  the  Large  Intestine 

A.     Cecum. 

Case  1. — N.  N.,  58  years,  F. 

ad  6. — About  Xoveniber,  1897,  there  began  complaints  at  the  pres- 
ent (November,  1899)  site  of  the  swelling,  namely,  a  dull  drawing,  press- 
ing sensation  above  Poupart's  ligament  on  the  right  side ;  these  complaints 
lasted  several  weeks  and  retrogressed.  Even  at  that  time  left  lateral 
decubitus  was  found  uncomfortable  because  it  produced  a  feeling  as  if  a 
heavy  body  fell  to  the  left.  For  the  past  three  months  the  bowels  have 
been  irregular,  constipation  alternating  with  diarrhea,  now  and  then 
colicky  pain  about  the  navel.  Of  late,  no  appetite.  Mild  manifestations 
of  cystitis.  Not  much  emaciation.  For  the  past  two  years  has  had 
constant  pain  in  the  back,  somewhat  aggravated  by  stooping. 

ad  7. — A  very  firm,  nodular  tumor,  about  the  size  of  an  infant's 
head,  in  the  ileocecal  region,  which  can  be  well  outlined,  especially  on  the 
inner  and  upper  surface,  outwardly  becoming  a  more  diffuse,  painful 
resistance.  Also  over  the  central  portions  of  the  swelling  there  is  a 
muffled  tympanitic  sound.  Distinct  respiratory  mobility,  otherwise 
mobility  is  slight.  No  distinct  intestinal  peristalsis.  Later  on,  loud 
peritoneal  friction  over  the  tumor-mass ;  mild  intestinal  rigidity  visible 
in  the  epigastrium;  splashing  zone  over  the  ascending  colon. 

November  23,  1899:  Total  paraplegia,  with  bladder  and  rectal  dis- 
turbance, disturbed  sensation  extending  upward  as  high  as  the  breasts. 
No  superficial  patellar  reflex.  Violent  pain  in  the  right  shoulder  though 
the  mobility  is  unhindered,  tender  places  over  the  sternum.  Very  slight 
edema  in  the  lower  extremities.  Mild  febrile  movements  of  late ;  slight 
jaundice.     No  particular  emaciation. 

ad  8. — Beginning:  About  November,  1897. 
Status  presens :  November  1,  1899. 
Autopsy:  November  28,  1899. 
Duration :  About  2  years. 

ad  9. — Autopsy  (Hofrat  Professor  Dr.  Weichselboum)  :  Ulcer- 
ating, stenosing  carcinoma  of  the  cecum  with  metastases  in  the  retro- 
peritoneal and  mesenteric  lymph  glands.  One  gland  perforated  into  the 
inferior  vena  cava.  Metastases  in  both  kidneys,  in  the  left  suprarenal 
gland,  in  both  ovaries,  peritoneum,  pleura,  lung,  liver,  dura  mater,  vault 
of  the  cranium,  vertebral  column  with  compression  of  the  dorsal  portion 
of   the    cord,    in    the    right    humerus,    sternum    and    in    the    hairy    scalp. 

Splenic  tumor. 

261 


262  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Epicrisis:  As  left  lateral  decubitus  produced  disagreeable  sensations 
in  the  ileocecal  region  even  two  years  before  death,  one  is  inclined  to 
assume  that  a  tumor  was  here  present  even  at  that  time. 

Lumbar  pain  was  a  constant  symptom.  At  no  time  during  the  course 
of  the  disease  were  there  any  distinct  symptoms  of  stenosis.  The  peri- 
toneal friction  sounds  found  over  the  tumor  are  deserving  of  note;  they 
are  found  much  more  fi-equcntly  with  ulcerating  tumors  of  the  stomach 
or  intestine  than,  for  example,  with  kidney  tumors  and  could  occasionally 
be  used  for  this  differential  diagnosis. 

Shortly  before  death  perforation  into  the  blood  current  had  led  to 
hematogenous  metastases  in  almost  all  the  organs,  the  skeletal  system 
sharing  in  it  to  a  particular  extent.  One  metastasis  in  the  vertebral 
colunm  led  to  paraplegia  and  ascending  paralysis.  The  metastases  in 
the  scalp  were  most  unusual,  and  they  had  been  surgically  diagnosed  as 
atheromas.  Besides  the  skeletal  metastases  (among  others  in  the  cranial 
vault)  there  were  also  metastases  in  both  ovaries,  but  without  appreciable 
enlargement  of  these  organs. 

Case  2.— W.  T.,  32  years,  M.    Agent. 

ad  2. — A  weakly  individual,  reddish-blond  mustache.  Between  the 
ages  of  9  and  19  often  had  severe  epistaxis.  I^eft  testicle  very  small,  in 
the  inguinal  canal. 

ad  5. — Never  was  seriously  sick. 

ad  6. — Since  November,  1906,  conspicuous  pallor.  Since  June, 
1907,  cardiac  palpitation  on  exertion.    Appetite  generally  good;  no  colics. 

ad  7. — A  tumor-mass  in  the  right  iialf  of  the  abdomen,  extending 
upward  as  high  as  2  finger  breadths  above  the  umbilicus,  posteriorly  as 
far  as  the  mammillary  line,  downward  as  far  as  3  finger  breadths  below 
the  umbilicus,  extending  across  somewhat  the  middle  line ;  firm  consistence ; 
slight  tenderness  on  pressure.  Over  the  tumor-mass  there  is  a  muffled 
tympanitic  sound,  bowel  noises  being  constantly  audible,  having  a  metallic 
sound,  and  limited  to  the  right  half  of  the  abdomen ;  some  indication  of 
ballottement.  Veins  of  the  right  abdominal  wall  standing  out  promi- 
nently. Glands  in  the  right  axilla.  Extreme  pallor  of  the  face.  Left 
leg  edematous,  calf  and  thigh  of  the  same  leg  very  tense;  small  cutaneous 
hemorrliages  on  the  anterior  and  internal  surface  of  the  right  thigh. 

Blood:  2,300,000  erythrocytes,  14,500  leucocytes,  30-40%  hemo- 
globin. 

Pulse:  108.  Chills  on  and  off  with  temperature  elevations  up  to 
39.6°  C. 

Feces:  Thin  fluid,  very  foul  odor,  lactic-acid  bacilli  moderately  abun- 
dant (confirmed  by  culture). 

ad  8. — Beginning:  About  November,  1906. 
Status  presens:  November  13,  1907. 
Autopsy:  March  7,  1908. 
Duration :  About  1  year,  4  months. 

ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Schlogenhaufer)  :  Car- 
cinoma of  the  cecum  with  great  dilatation  of  the  lumen,  adhesion  to  ad- 


CARCINOMA    OF    THE    LARGE    INTESTINE  263 

jacent  loops  of  small  bowel.  Right  testicle  fixed  in  the  ingiiinal  canal. 
Old  thrombi  in  both  veins  of  the  thigh,  Splenic  enlargement,  red  bone 
marrow  in  the  right  femur.  An  ulcer  at  the  lesser  curvature  in  the  py- 
loric portion  of  the  stomach  (about  2l/>  cm  in  diameter)  adhei'ent  to  the 
liver.      Tubercular  lymplioma  in  the  right  axilla. 

Histological  examination  of  the  cecal  tumor:  colloid  carcinoma. 

Epicrisis:  In  this  instance  the  cancer  attacked  a  youthful  individual 
of  a  general  tubercular-lymphatic  appearance.  Tuberculosis  of  the 
axillary  lymph  glands  on  the  right  side.      Severe  epistaxis  during  youth. 

During  the  entire  course  there  were  no  symptoms  of  stenosis. 

Extreme  pallor  was  the  dominant  feature  of  the  disease,  so  much  so 
that  the  case  was  presented  to  me  as  one  of  pernicious  anemia. 

The  dilatation  of  the  veins  in  the  right  half  of  the  abdomen  in  and 
of  themselves  had  to  remind  one  of  a  local  abdominal  process.  The 
accompanying  sporadic  chills  are  probably  to  be  interpreted  as  sympto- 
matic of  ulceration  (secondary  infection). 

The  subjective  symptoms  on  part  of  the  digestive  tract  were  very 
slight,  adynamia  and  anemia  occupying  the  foreground. 

Case  3.— N.  K.,  60  years,  F. 

ad  3. — Had  measles  as  a  child. 

ad  6.- — In  October,  1906,  had  some  obscure,  febrile  condition  last- 
ing one  week  (influenza.?)  ;  to  this  there  became  associated  stomach  com- 
plaints, namely,  loss  of  appetite,  later  on  pain  immediately  after  intake 
of  food,  localized  chiefly  in  the  left  side  of  the  epigastrium ;  frequent 
heartburn  and  eructation  of  gas.  Painful  attacks,  often  accompanied  by 
loud  rumbling.  Stool  usually  regular,  except  on  one  occasion,  at  a  time 
when  there  was  very  severe  pain,  it  was  hard  and  the  bowels  moved  only 
with  the  aid  of  an  enema. 

ad  7. — April,  1907:  Subjectively  the  above-described  symptoms; 
subfebrile  condition,  temperature  often  going  over  37°  C.  No  distinct 
tumor  can  be  felt.  July,  1907:  A  hard  tumor,  about  the  size  of  a  walnut, 
palpable  in  the  ileocecal  region ;  tendency  to  diarrhea.  Frequent  pain  in 
the  lower  abdominal  region,  followed  by  tenesmus,  which  is  very  urgent. 
Temperature  frequently  above  38°  C.  (During  the  course  of  the  disease, 
three  chills  without  accompanying  pain.)  Quiet  heart  action,  not  in- 
creased in  frequency.  Color  of  the  face  yellowish  cachectic  with  capillary 
dilatations  in  the  cheeks. 

ad  8. — Beginning:  October,  1906. 

Status  presens :  April  and  July,  1907. 
Operation:  July,  1907. 

ad  9. — Operation  (Hofrat  Professor  Dr.  Hochenegg)  :  Carcinoma 
of  the  cecum.      Resection. 

Epicrisis:  In  this  case  the  alarming  symptom  was  the  fever  of  very 
irregular  type,  occasionally  becoming  so  much  exacerbated  as  to  induce 
chills.  The  pain  in  the  epigastrium  often  immediately  after  ingestion  of 
food,  accompanied  by  heartburn,  could  lead  one  to  erroneously  suspect 
a  gastric  lesion. 


264  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Only  in  the  later  course  of  the  disease  did  the  colic  of  the  large  bowel 
and  tenesmus  occur.  The  quiet  pulse,  never  becoming  rapid,  spoke  against 
the  assumption  of  any  kind  of  occult  purulent  focus  as  the  cause  of  the 
fever  and  the  chills.     Never  any  symptoms  of  intestinal  constriction. 

Case  4. — A.  V.,  45  years,  M. 

ad  1. — No  cancerous  disease  in  the  family;  mother  is  healthy,  74 
years  of  age. 

ad  2. — Habitus  quadratus ;  hair  blond,  bristly,  iris  blue.  Numer- 
ous angiomas.  Four  months  ago  had  a  painful  swelling  of  the  dorsum 
of  left  foot,  lasting  three  and  a  half  months. 

ad  3. — Smallpox  at  6  years  of  age. 

ad  4. — Always  intolerant  toward  fat  foods. 

ad  5. — Was  always  healthy ;  heavy  smoker. 

ad  6. — About  May,  1904,  the  patient's  attention  was  called  to  his 
pale  facial  color;  on  weighing  himself  found  that  he  had  lost  20  kg.  Be- 
came irritable.  Since  September  of  this  year  the  bowels  are  somewhat 
irregular,  now  and  then  fluid,  following  that  again,  constipated;  the 
stools  became  very  bad  smelling.  Of  late,  now  and  then,  griping  and 
some  rumbling  in  the  lower  abdominal  region.  For  the  past  month  fre- 
quent sick  feelings  with  vomiting  of  sour,  greenish  masses,  especially 
toward  9  and  11  a.m.  Frequent  heartburn,  decrease  of  appetite.  For 
the  past  two  weeks  vomiting  and  dizziness  on  walking  about  for  some 
time ;  a  month  ago  night-sweats,  some  cough  and  fever.  No  pain  in  the 
back.  Tenderness  to  pressure  on  the  right  side  of  the  abdomen.  With 
lateral  position  mild  drawing  sensation  in  the  abdomen  in  a  direction 
from  right  to  left. 

ad  7. — Uneven  tumor-masses  in  the  ileocecal  region,  with  but  little 
respiratory  mobility,  thrill  on  pulsation;  on  and  off,  slight  gurgling  over 
the  tumor  mass.  Splashing  in  the  stomach  several  hours  after  breakfast. 
HCl  positive  after  test-breakfast. 

Feces:  Strongly  alkaline  reaction,  very  foul  smelling;  a  few  spiro- 
chetes, abundance  of  very  actively  motile  rod-shapes. 

Blood:  3,000,000  erythrocytes,  4,200  leucocytes,  407o  hemoglobin. 
Urine:  Indican  reaction  strongly  positive. 

ad  8. — Beginning:  About  Ma}-,  1904. 

Status  presens :  October  3,  1905. 
Operation:  October  9,  1905. 

ad  9. — Operation :  I^arge  carcinomatous  tumor  in  the  region  of  the 
cecum. 

Epicrisis:  Just  as  in  Case  3,  so  also  here,  the  gastric  symptoms  come 
prominently  into  the  foreground:  heartburn,  biliary  vomiting,  anorexia. 
Also  here,  though  rather  intercurrently,  there  is  fever  accompanied  by 
night-sweats.  Slight  disturbances  on  part  of  the  bowel:  never  any  symp- 
toms of  constriction,  only  mild  irregularities  in  bowel  movements,  light 
colickv  pain  in  the  lower  abdominal  region,  accompanied  by  rolling. 

Bacteriologically  the  stools  contain  a  few  spirochetes  and  in  addition 
very  actively  motile  rod-shapes. 


CARCINOMA    OF    THE    LARGE    INTESTINE  265 

The  rod-shapes  in  normal  stools  show  only  molecular  motion  and  never 
exhibit  any  active  movements. 

Pallor  and  emaciation  in  this  instance  count  among  the  initial  symp- 
toms, at  least  so  far  as  the  history  shows. 

B.     Hepatic  Flexure 

Case  1.— C.  G.,  53  years,  F. 

ad   1. — Father  died  of  tuberculosis, 
ad  3. — No  infectious  diseases. 
ad  5. — Always  healthy  until  the  spring  of  1904. 
ad  6. — In  the  spring  of  1904  beginning  of  cramp-like  pain  in  the 
belly,  occurring  now  and  then,  especially  if  the  patient  lay  down  imme- 
diately after  dinner  or  supper.      If  dinner  was  taken  at   12  o'clock  the 
pain  began  at  2  o'clock ;  the  pain  occurring  in  the  evening  often  lasted  till 
midnight.      The  quality  and  quantity  of  the  food  are  said  to  have  made 
no  difference;  after  eating  sauerkraut  she  felt  better.      Painful  attacks 
often  accompanied  by  loud  rumbling. 

In  the  autumn  of  1904;  the  appetite  became  bad,  there  came  on  a  dis- 
inclination toward  meat. 

In  November,  1904,  a  swelling  was  noticed  in  the  right  side  of  the 
abdomen.  Of  late  frequent  bitter  tasting  vomitus ;  bowel  movements 
fairly  regular  during  this  entire  time,  except  that  occasionally  there  would 
be  no  movement  for  two  days  at  the  longest.  Now  and  then  pain  in  the 
back ;  no  fever. 

ad  7. — Upper  surface  of  the  tongue  smooth,  atrophic,  dry.  On 
the  right  side  in  the  mammary  line,  continuous  with  the  border  of  the 
liver,  there  is  a  hard,  protuberant,  uneven  tumor-mass,  vibrating  with 
pulsation,  and  freely  movable  with  respiration.  Over  the  tumor-mass 
there  is  a  muffled  tympanitic  resonance,  and  anterior  to  it  no  intestinal 
loop  can  be  felt.  The  tumor-mass  cannot  with  certainty  be  marked  off 
from  the  hepatic  border.  On  and  off,  periumbilical  peristalsis ;  at  the 
same  time  there  appears  a  portion  of  gut  corresponding  in  locality  to 
the  cecum  over  which  splashing  can  be  elicited.  Color  of  the  face  pale 
yellowish;  no  edemas.   Transient  temperature  elevations  of  38°  C. 

Feces:  Mucous  shreds  saturated  with  blood,  increase  of  the  Gram- 
positive  flora. 

Urine:  Indican  not  increased. 
Blood:  7,300  leucocytes,  40%  hemoglobin, 
ad  8. — Beginning:  About  March,  1904. 

Status  presens:  January  11,  1905. 
Operation:  January   19,   1905. 
Autopsy:  January  21,  1905. 
Duration  :  About  10  months, 
ad  9. — Operation    (Clinic   Hofrat   Professor  Dr.  J.   Hochenegg)  : 
A  carcinoma,  as  big  as  a  child's  head,  in  the  hepatic  flexure  with  great 
constriction  and  ulceration.      Cecum  much  distended.      The  tumor  reached 
to  the  duodenum  from  which  it  had  to  be  dissected.      In  addition  to  this, 


266  TUMORS    OF    THE    ABDOMINAL    VISCERA 

autopsy  disclosed  metastases  in  both  ovaries  (size  of  a  child's  fist)  and  in 
the  retroperitoneal  glands. 

Epicrisis:  This  is  another  case  in  which  secondary  gastric  symptoms 
are  not  lacking:  vomiting,  meat  anorexia,  pains  occurring  two  hours 
after  dinner.  The  latter,  despite  the  short  interval  of  time,  are  probably 
to  be  interpreted  as  intestinal  colics,  and  in  another  place^''  I  have 
pointed  out  with  emphasis  the  fact  that  the  interval  of  time  between  the 
intake  of  food  and  the  occurrence  of  pain  can  only  with  great  difficulty 
be  employed  for  the  purpose  of  localizing  a  painful  process. 

Bowel  movenjents  fairly  regular. 

The  cecum  takes  part  in  the  intestinal  peristalsis,  and  over  it  distinct 
splashing  can  be  heard. 

The  pulsatory  vibration  of  the  tumor  in  the  colon  is  worthy  of  note; 
the  bridging  over  toward  the  aorta  being  established,  as  shown  at  au- 
topsy, by  retroperitoneal  glands.  The  lingua  mucosa  showed  atrophic 
changes. 

The  feces  contained  numerous  Gram-positive  rod-shapes  reminding 
one  of  lactic-acid  bacilli. 


Case  2.— F.  R.,  32  years,  M. 

ad  2. — Of  a  somewhat  weakly  constitution,  but  otherwise  healthy. 

ad  3. — Has  had  no  infectious  diseases. 

ad  5. — Was  always  healthy. 

ad  6. — In  September,  1907,  there  began  pressure  in  the  stomach, 
colicky  pains  came  on  in  the  epigastrium,  accompanied  by  hiccough,  so 
violent  that  morphine  injections  were  necessary.  The  appetite  dimin- 
ished. In  December,  1907,  the  appetite  again  improved,  and  it  is  said 
that  during  the  months  of  January,  February,  and  March,  1908,  the 
patient  gained  14  kg  in  weight.  In  the  beginning  there  was  constipation, 
later  on  diarrhea  with  discharge  of  blood  and  mucous.  In  October,  1908, 
a  swelling,  as  big  as  a  hen's  egg,  was  found  in  the  abdomen  on  the  right 
side;  this  is  said  to  have  disappeared  again  {?).  In  January,  1909,  re- 
currence of  severe  pain  in  the  epigastrium  and  anorexia,  accompanied  by 
heartburn ;  stool  inclined  to  diarrhea. 

ad  7. — A  slender,  much  emaciated  individual  with  a  slightly  en- 
larged abdomen,  great  feeling  of  weakness  and  severe  retromalleolar 
edema.  On  the  right  side,  on  the  level  with  the  umbilicus,  a  tumor- 
mass,  as  big  as  a  child's  head,  with  a  tympanitic  sound  over  its  central 
portions ;  no  vascular  murmurs ;  metallic  borborygmi  often  audible  over 
the  area  of  the  swelling.  No  bowel  peristalsis.  Tympanitic  resonance 
over  the  liver.  Heart-sounds  are  clear.  Subfebrile  course  (often  over 
37°  C,  on  and  off  38°  C). 

Feces:  Gray,  putrid,  somewhat  foamy,  strongly  alkaline,  mostly  fluid, 
containing  brown-colored  mucous ;  blood-coloring  material  demonstrable 


"  R.  Schmidt.     Die  Schmerzphanomene  bei  inneren     Erkrankungen,  etc.    II.  Edition, 
1910,  Wilhelm  Braumuller. 


CARCINOMA    OF    THE    LARGE    INTESTINE  267 

only  by  chemical  test.     Microscopic  examination:  pus-cells,  many  fatty 
acid  needles  and  neutral  fat. 

Urine:  Suggestion  of  a  diazo  reaction. 

Blood:   27,()()()   leucocytes.      Sahli's  desmoid   reaction   negative, 
ad  8. — Beginning:   September,   1907. 

Status  presens :  January   11,  1909. 
Autopsy:  February   16,   1909. 
Duration:   About    11/2   ycfii'>>- 
ad  9. — Autopsy    (Prosector   Professor   Dr.   Fr.   Schlagenhaufer)  : 
Circular,  ulcerating  carcinoma  of  the  hepatic  flexure  of  the  colon  (in  this 
area  adhesions  to  the  anterior  abdominal  wall  and  stomach)  ;  multiple 
metastases  in  the  liver. 

Epicrisis:  As  is  usual  in  those  cases  in  which  carcinomas  develop  at 
a  relatively  young  age,  so  also  here  we  are  concerned  with  a  constitu- 
tion that  has  been  rather  weak  from  childhood.  Also  here  at  the  begin- 
ning and  during  the  further  course  of  the  disease  there  were  present 
pronounced  gastric  symptoms,  such  as  anorexia  and  heartburn ;  the 
initial  attacks  of  colic  appeared  in  the  epigastrium  and  were  accom- 
panied by  hiccough.  When  in  the  early  part  of  1908,  about  a  year 
before  death,  the  appetite  came  back  again,  the  patient  gained  14  kg  in 
weight.  Manifestations  of  constriction  were  lacking  during  the  entire 
course.     Neither  was  there  ever  any  vomiting. 

The  particularly  bad  reduction  of  fat  was  shown  by  the  appear- 
ance of  neutral  fat  (pancreas  unchanged  at  autopsy). 

The  considerable  leucocytosis   (27,000)   is  worthy  of  note. 


ad  4. — Irregular    bowel    movements    for    the    last    three    or    four 


Case  3.— M.  K.,  66  years,  F 

years. 

ad  5. — In  1893  decided  enlargement  of  the  abdomen ;  in  the  sur- 
gical clinic  of  Hofrat  Professor  Dr.  E.  Alberts  13  litres  of  fluid  were 
withdrawn  and  a  tumor  extirpated  (ovarian  cyst.'')  ;  the  patient  recov- 
ered rapidly  and  was  healthy  until  the  summer  of  1901. 

ad  6. — In  July,  1901,  after  eating  fruit  and  cucumber  salad,  vio- 
lent colicky  pain ;  in  this  connection  the  attending  physician  is  quoted 
as  saying  that  a  portion  of  gut  in  the  upper  right  quadrant  became 
erect,  exhibiting  a  horizontal  and  a  vertical  limb.  When  this  disap- 
peared there  was  also  a  disappearance  of  the  pain.  Since  then  there  is 
anorexia.  Up  to  the  present  time  there  have  been  six  or  seven  attacks 
of  pain;  the  first  attack  occurred  at  5  p.m.,  the  others  often  at  night. 
The  patient  helps  herself  during  these  attacks  by  massaging  these  erected 
parts;  with  it  there  is  great  noise,  a  sort  of  "driving  about."  During 
the  painful  attacks  there  is  a  cessation  of  bowel  movements  and  dis- 
charge of  flatus. 

Discharge  of  flatus  aff'ords  immediate  relief.  After  the  attacks  of 
pain  now  and  then  there  is  vomiting,  on  one  occasion  smelling  very  bad  ; 
often  also  odorless  eructation.  Stools  often  are  fetid,  contain  mucus 
in  rather  large  quantities,  no  blood.     Great  feeling  of  weakness,  emacia- 


268  TUMORS    OF    THE    ABDOMINAL    VISCERA 

tion  to  the  extent  of  20  kg.  Since  the  beginning  of  the  disease  decided 
falling  out  of  the  hair.  Of  late,  especially  since  the  end  of  December, 
1901,  the  attacks  of  pain  follow  each  other  closely,  mostly  half  an  hour 
before  the  bowels  move,  after  which  tenesmus  continues ;  pain  especially 
in  the  right  upper  quadrant,  without  radiation.  When  the  pain  becomes 
very  intense  there  is  a  slight  chill  without  subsequent  feeling  of  heat. 
When  lying  on  the  left  side  there  is  a  feeling  as  if  something  in  the 
abdomen  would  sink  to  the  left ;  the  patient,  therefore,  rests  on  her 
back,  with  the  legs  drawn  up. 

ad  7. — A  somewhat  uneven,  hard  tumor,  not  clearly  definable 
against  the  border  of  the  liver,  possessing  respiratory  mobility,  sensitive 
to  pressure ;  over  same  there  is  tympanitic  resonance,  and  here  and 
there  bowel  noises  are  audible,  especially  on  deep  inspiration.  No  bal- 
lottement.  Diarrhea  with  tenesmus.  Edema  over  the  sacrum  and  some 
indication  of  it  behind  the  internal  malleolus.  Frequent  moderate  tem- 
perature elevations  over  37°  C.  during  the  attacks  of  pain,  reaching 
39°  C. 

Feces:  Much  mucus.     Increase  of  Gram-positive  cocci. 

Urine:   Strongly  positive  indican   reaction,   abundant   urobilinogen. 

Blood:  3,500,000  erythrocytes,  7,500  leucocytes, 
ad  8. — Beginning:   July,   1901. 

Status  presens:  March  12,  1902. 
Autopsy:  August,  1902. 
Duration:  About  13  months, 
ad  9. — Autopsy  (Professor  Dr.  O.  Stoerk)  :  Ulcerating  carcinoma 
of  the  hepatic  flexure  of  the  colon  with  multiple  perforations   into  the 
upper  part  of  the  duodenum  and  the  pylorus.     Atheroma  of  the  aorta 
with  parietal  thromboses. 

Epicrisis:  In  the  previous  history  of  the  patient  we  encounter  a 
swelling  formation,  which  was  treated  surgically,  and  which  to  all  ap- 
pearances was  an   ovarian  cyst. 

In  July,  1901,  i.  e.,  thirteen  months  prior  to  death,  the  carcinoma 
made  its  appearance  with  colicky  pain  and  localized  peristalsis  in  the 
region  of  the  hepatic  flexure,  provoked  by  an  error  in  diet. 

From  this  time  on  there  is  on  the  average  one  attack  of  colic  every 
month ;  pain  localized  chiefly  in  the  right  upper  quadrant,  accompanied 
by  loud  "rolling,"  by  symptoms  of  regurgitation  such  as  vomiting,  eruc- 
tation, by  mild  chills  and  temperature  up  to  39°  C. 

Of  late  the  intestinal  nature  of  the  pain  is  betrayed  by  the  fact  that 
it  is  associated  with  bowel  movements  which  are  accompanied  and  out- 
lasted by  tenesmus. 

Left  lateral  position  causes  a  feeling  in  the  belly  as  if  something 
were  drawn  to  the  left. 

The  stools  are  mostly  fluid,  containing  much  mucus,  but  never  any 
blood  which  can  be  recognized  macroscopically. 

Since  the  beginning  of  the  disease  falling  out  of  the  hair. 


CARCINOMA    OF    THE    LARGE    INTESTINE  269 

Case  4. — P.  Ch.,  59  years,  M.    Hatmaker. 

ad    1. — Parents  died  at  a  very  old  age. 

ad  5. — Always  was  healthy ;  for  several  years,  on  and  off,  there 
has  been  diarrhea,  occurring  without  apparent  cause.  It  is  stated  that 
four  years  ago,  after  eating  spoiled  pork,  there  was  jaundice  for  two 
days. 

ad  6. — At  the  end  of  October,  1903,  rapid  increase  in  the  cir- 
cumference of  the  abdomen;  during  the  past  months  much  emaciation. 
Swelling  in  the  legs  without  any  cardiac  complaints.  No  pain  in  the 
back.     Appetite  bad  for  the  past  month.     Alcohol  is  admitted. 

ad  7.- — No  icterus.  Abdomen  greatly  distended,  epigastric  venous 
plexus.  Ascites.  Liver  dulness  small,  in  streaks.  Severe  retromalleolar 
edema  on  the  inner  side.  Tendency  to  subnormal  temperature  below 
36°  C.  Long  terminal  coma  with  slowing  of  respiration  and  heart  ac- 
tion ;  just  before  death  there  was  vomiting  of  blood. 

Aspirated  fluid:  "IMilky"  turbidity,  without  cellular  elements,  sp.  gr., 
1008. 

Urine:  No  urobilinogen;  strong  indican  reaction. 

Stool:  "Dysentery-like,"  containing  much  mucus  and  some  blood. 

Blood:  11,000  leucocytes. 

ad  8.^ — Status  presens:  December  12,  1903. 

Autopsy:  December  31,  1903. 
ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Atrophic  cirrhosis  of 
the  liver,  with  splenic  tumor  and  esophageal  varices.  Colloid  carcinoma 
of  the  hepatic  flexure  of  the  colon  (large  glandular  metastases  around  the 
pancreas,  lymph-vessels  dilated,  metastases  in  both  suprarenal  bodies 
and  both  pleur;e.  Metastases  in  the  peritoneum  and  in  the  osseous  sys- 
tem).    Chylous  ascites. 

Epicrisis:  This  case  illustrates  the  not  altogether  too  rare  complica- 
tion of  a  liver  cirrhosis  with  a  malignant  neoplasm  of  the  bowel.  L^nusual 
for  the  assumption  of  a  simple  cirrhosis  was  the  rapid  course  from  the 
beginning  of  the  ascites  (October,  1903)  until  death  (December,  1903)  ; 
also  unusual  was  the  "milky"  nature  of  the  ascites,  which  was  explained 
by  a  compression  of  the  chyle  vessels  (metastases  in  the  radix  mesen- 
terii)  ;  furthermore,  there  was  absent  leukopenia  (11,000  leucocytes)  fre- 
quently met  with  in  cirrhosis  of  Laennec. 

The  terminal  stage  of  the  disease  had  the  marks  of  a  cirrhosis :  throm- 
bosis of  the  portal  vein,  hematemesis,  hepatic  coma. 

Despite  the  serious  disease  of  the  liver,  urobilinogen  was  absent  in 
the  urine,  perhaps  as  a  result  of  poor  absorption  of  urobilinogen  from 
the  bowel  due  to  thrombosis  of  the  portal  vein. 

The  intestinal  disease  manifested  itself  by  "dysentery-like"  stools. 
S3nnptoms  of  constriction  were  permanently  absent. 

As  is  so  frequently  the  case  in  malignant  diseases,  the  previous  his- 
tory mentions  longevity  of  the  parents. 


270  TUMORS    OF    THE    ABDOMINAL    VISCERA 


C.  Splenic  Flexure  of  the  Colon 

Case  1. — R.  M.,  41  years,  M. 
ad  3.— No  I.  D.  C. 

ad  5. — Was  always  healthy. 

ad  6. — Since  January,  1906,  anorexia  and  rapid  emaciation,  says 
that  he  lost  30  kg  in  weight.  Otherwise  no  initial  complaints.  In  ]March 
of  this  year  diarrhea  set  in,  two  movements  a  day,  which  became  intense 
about  the  end  of  June  this  ^^ear.  Toward  the  end  of  May  of  this  year 
a  Karlsbad  cure  was  recommended,  but  he  could  not  stand  it.  At  that 
time  there  appeared  the  first  attacks  of  colic,  which  since  then  have 
recurred  very  often  at  intervals  of  one  or  two  days.  They  extend  over 
the  entire  abdomen  and  are  ushered  in  hy  loud  rumbling;  they  occur 
especially  at  night.  Bowels  move  once  a  day,  though  not  very  copiously, 
and  not  containing  any  large  admixtures  of  mucus  or  blood.  Very  often 
there  is  odorless  eructation  per  os,  but  little  gas  is  discharged  per  anum. 
Lying  on  the  left  side  more  easily  provokes  colick\'  pain.  In  September 
of  this  year  the  appearance  was  not  yet  suspicious  of  cancer.  The 
patient  is  said  to  have  vomited  "coffee  grounds"  once. 

ad  7. — Abdomen  often  suddenly  much  distended,  exhibiting  bulg- 
ing areas  resulting  from  the  protulx>rance  of  inflated  intestinal  loops; 
no  distinct  tumor  can  be  felt.  Succussion  yields  loud  splashing  sounds. 
Retromalleolar  edemas. 

Rectal  finding:  Ampulla  conspicuously  wide. 

Urine:  Much  sediment. 

Feces:  Abundance  of  very  thin.  Gram-negative  rod-shapes, 
ad  8. — Beginning:  January,  1906. 

Status  presens:  October  11,  1906. 
Operation  and  autopsy:  October,  1906. 
Duration:  About  10  months, 
ad  9. — Autopsy:  Soft  ulcerating  carcinoma  of  the  splenic  flexure 
of  the  colon.     Perforating  peritonitis. 

Epicrisis:  Anorexia  and  emaciation  are  the  first  clinical  manifesta- 
tions (January,  1906).  Only  several  months  later  (May-June,  1906) 
do  bowel  sj^mptoms  appear,  namely,  fluid  bowel  movements  and  colicky 
pain.  The  latter  is  accompanied  by  loud  rumbling,  and  occurs  particu- 
larly at  night ;  lying  on  the  left  side  favors  their  occurrence.  This 
peculiarity  points  to  some  localized  cause  of  same. 

In  September,  1906,  there  existed  distinct  symptoms  of  bowel  con- 
striction ;  dilatation  of  the  bowel  with  general  splashing  and  intestinal 
peristalsis ;  bowel  moved  daih'  and  were  for  the  most  part  fluid. 

Transiently  there  was  "coffee-ground"  vomiting,  which  is  sometimes 
peculiar  to  bowel  stenoses. 

The  abnormal  width  of  the  ampulla  is  worthy  of  attention ;  according 
to  Hochenegg,  it  is  an  accompanying  manifestation  of  low-down  con- 
strictions of  the  large  gut. 


CARCINOIMA    OF    THE    LARGE    INTESTINE  271 

Case  2.— K.  K.,  73  years,  M. 

ad  3. — Kcincnibers  having  had  typhoid. 

ad  5. — Otherwise  was  never  sick. 

ad  6. — Chiims  to  have  lost  20  kg  in  weight  since  April,  1908 ;  com- 
plains of  eructation,  vomiting  after  sour  foods,  weakness  and  great  fa- 
tigue. Whilst  in  bed  from  September  28th  to  October  19th,  gained  2.5 
kg  in  weight  and  felt  perfectly  well.  In  December,  1908,  recurrence  of 
loss  of  appetite,  vomiting  about  two  hours  after  eating.  Bowels  con- 
stipated. No  spontaneous  pain,  no  tenderness  to  pressure  in  the  abdo- 
men. On  and  off  slight  increases  in  temperature.  Just  before  death 
torturing  hiccough ;  everything  is  vomited. 

ad  8. — Beginning:  April,   1908. 

Autopsy:  January  3,  1909. 
Duration:  9  months. 

ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  ScJilagenhaufer)  :  Ul- 
cerating colloid  cancer  of  the  transverse  colon  at  the  splenic  flexure  in- 
vading the  tail  of  the  pancreas  and  a  loop  of  small  intestine.  Hemoside- 
rosis of  the  spleen ;  arteriosclerosis. 

Epicrisis:  Gastric  symptoms  dominate  the  clinical  picture  of  the 
disease  and  usher  it  in :  eructation,  vomiting,  anorexia  of  varying  de- 
gree. Tendency  to  constipation  is  the  only  intestinal  symptom.  No 
symptoms  of  stenosis. 

D.  Sigmoid  Flexure 

Case  i. — J.  B.,  45  years,  M.    Lithographer. 

ad   1. — Father  died  at  62  of  tuberculosis. 

ad  4. — Bowel  irregularities  since  1883. 

ad  5. — At  15  enlarged  cervical  glands;  at  his  work  had  to  handle 
lead  and  anilin  dyes. 

ad  6. — Since  1898  noticed  a  sensitiveness  of  the  bowel,  so  that  pain 
occurred  after  errors  in  diet,  but  this  pain  soon  disappeared.  In  January, 
1899,  occurrence  of  urinary  difficulties,  with  tenesmus  and  pain  in  the 
pelvis,  urine  having  a  foul  odor.  On  February  22,  1899,  after  drinking 
ice-cold  beer,  there  was  severe  abdominal  pain,  accompanied  by  feverish 
feeling  and  vomiting;  at  the  same  time  constipation,  no  discharge  of 
flatus.      Appendicitis  was  diagnosed. 

ad  7. — March  5,  1900:  Abdomen  distended,  lively  diffuse  peristal- 
sis with  loud  squirting  sounds,  especially  in  the  epigastrium.  There  is 
a  bulging  in  the  left  lower  quadrant ;  here  and  underneath  the  umbilicus 
the  tension  of  the  abdominal  walls  is  at  its  maximum  ;  left  flank  some- 
what more  tense  than  the  right.  Heart-sounds  can  be  distinctly  heard 
also   in   the   right   flank.      No   edemas. 

March  31,  1900:  Pale  yellowish  discoloration,  tongue  very  dr}'.  Ex- 
treme meteorism,  in  consequence  of  which  peristalsis  is  less  clearly  visibhi 
than  formerly';  loud  bowel  noises.  Hiccough.  Attack  of  colic  accom- 
panied by  lumbar  pain.  Colic  radiates  into  the  anus.  Immobilization 
in  dorsal  position.      Mild  rctromalleolar  edemas. 


272  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Urine:  Great  urobilinuria. 

Feces:  Pulpy,  yellowish-brown,  very  fetid,  foamy.  Microscopically: 
Numerous  heaps  of  cocci,  staining  blue  with  Lugol.  Toward  the  end: 
Chills,  collapse  (April  6th). 

April  7,  1900:  The  patient  feels  better,  the  bowel  noises  have  ceased, 
but  the  abdomen  is  very  rigid;  in  the   forenoon  still  had  a  fluid  bowel 
movement;  afternoon,  collapse  and  death, 
ad  8.— Beginning:  1898(?). 

Status  presens:  March  5  and  March  30,  1900. 
Autopsy:  April  7,  1900. 
ad  9. — Autopsy  (Docent  Dr.  K.  Landsteiner)  :  ring-shaped  car- 
cinoma of  the  sigmoid  flexure,  50  cm  above  the  anal  opening,  with  many 
adhesions  of  the  intestines  in  the  region  of  the  true  pelvis  and  metastases 
in  the  liver.  Great  hypertrophy  of  the  entire  large  and  small  intestine, 
enormous  dilatation  of  the  cecum  with  perforation  of  same,  and  mani- 
fold diastasis  of  the  serosa  about  the  large  bowel,  particularly  the  cecum. 
Purulent  perforative  peritonitis.  Bullous  edema  of  the  vesical  mucosa. 
Thrombosis  of  the  left  femoral  vein  and  edema  of  the  left  leg.  Embolism 
in  the  larger  branches  of  both  pulmonary  arteries. 

Epicrisis:  The  beginning  of  the  disease  cannot  be  definitely  ascer- 
tained. Nevertheless,  it  is  very  probable  that  the  attacks  of  pain  occur- 
ring in  connection  with  the  dietetic  errors  in  1898  are  to  be  referred 
to  the  carcinoma. 

It  is  well  known  that  the  first  symptoms  of  gastric  or  intestinal  car- 
cinoma frequently  manifest  themselves  after  such  unintentionally  pro- 
duced alimentary  tests.  Early  diagnosis  will  gain  much  if  similar  tests 
are  designedly  undertaken  in  a  given  case  of  suspected  cancer. 

The  symptoms  of  cystitis  appearing  in  January,  1899,  may  also 
have  been   of  intestinal   genesis. 

The  "appendicitis"  diagnosed  in  February,  1899,  is  very  probably 
to  be  referred  to  the  cecum ;  it  was  at  this  site  that  the  last  stage  of  the 
disease  developed  through  the  occurrence  of  perforation  due  to  over- 
distention  ahead  of  the  constriction.  The  particularly  strong  tension 
in  the  left  flank  could  lead  one  to  think  of  a  low  down  colon  afl'ection ; 
likewise  the  radiation  of  the  colicky  pain  toward  the  anal  opening. 

Case  2. — B.  J.,  42  years,  F.    Teacher. 

ad   1. — Mother  is  living  and  well. 

ad  2. — In  April,  1900,  had  pain  in  both  wrist-joints,  lasting  two 
weeks,  without  fever. 

ad  3. — As  a  child  had  smallpox. 

ad  5. — Otherwise  "was  always  healthy. 

ad  6. — In  May,  1900,  had  pain  in  the  back,  sacrum  tender  on 
pressure.  Even  in  the  month  of  April  feeling  of  pressure  in  the  epigas- 
trium ;  in  walking  the  patient  stooped  forward ;  could'  eat  but  little,  as 
otherwise  there  was  a  feeling  of  great  pressure  in  the  epigastrium.  At 
that   time   there   was   severe   constipation ;   even   after   taking   cathartics 


CARCINOMA    OF    THE    LARGE    INTESTINE  273 

the  feces  came  in  the  shape  of  small,  oval  pieces  covered  with  mucus. 
Now  and  then  involuntary  discharge  of  hlood-streaked  mucus.  The 
act  of  defecation  was  accompanied  by  pain  and  tenesmus. 

In  July,  1900,  a  swelling  was  felt  in  the  epigastrium;  at  that  place 
there  was  pain  on  pressure,  also  on  coughing  and  deep  breathing.  Since 
the  beginning  of  the  disease  there  is  emaciation,  fatigue,  the  appetite 
remaining  good.  No  vomiting.  Menstruation  has  ceased  since  the  be- 
ginning of  the  disease. 

September  21,  1900:  Intense  pain  on  the  right  side  of  the  thorax 
on  coughing,  sometimes  radiating  over  the  lumbar  region  and  even  the 
outer  side  of  the  thigh ;  pain  also  on  inclining  forward,  or  when  lying 
on  the  right  side.  On  the  right  side  posteriorly  about  a  hand's  breadth 
below  the  angle  of  the  scapula  a  sensitive  area.  Troublesome  dry  cough 
without  expectoration.  Great  feeling  of  pressure  immediately  after  in- 
take of  food.  Tenderness  on  deep  pressure  about  Poupart's  ligament, 
ad  7. — Enormously  diffuse  enlargement  of  the  liver,  the  organ 
feeling  very  firm ;  over  it  a  blowing,  systolic  murmur.  Peritoneal  fric- 
tion over  the  left  lobe  of  the  liver,  where  it  can  also  be  felt,  on  the  right 
side  audible  only.  Ascites  and  bilateral  pleural  effusion.  Venous  dila- 
tations on  the  right  side,  posteriorly,  below,  alongside  the  vertebral  col- 
umn, and  on  the  left  side  anteriorly  over  the  abdomen.  Very  severe 
edema  in  the  lower  extremities.  The  lower  abdominal  region  greatly 
distended  by  meteorism.  Pain  after  every  intake  of  solid  or  liquid  food. 
Toward  the  end  gallop  rhythm  with  pseudo-pericardial  friction  (due  to 
perihepatitis !). 

ad  8. — Beginning:   April,   1900. 

Status  presens:  September  21,  1900. 
Autopsy:  September  26,  1900. 
Duration :  6  months, 
ad  9. — Autopsy   (Professor  Dr.   H.  Albrecht)  :  Ulcerating  carci- 
noma of  the  sigmoid  flexvire,  with  cancerous  thrombosis  of  the  left  iliac 
vein  and  vena  inf.  cava.     Enormous  enlargement  of  the  liver  as  a  result 
of  metastases.      Numerous   metastases   in   both  lungs   and   in   the   retro- 
peritoneal   lymph-glands.      Complete    compression    of    both    low^er    lobes 
from  hydrothorax.     Chylous  ascites.     Chronic  perihepatitis. 

Epicrisis:  Only  those  symptoms  will  here  be  mentioned  which  do  not 
emanate  from  the  metastatic  processes  in  the  liver,  but  which  have  a 
connection  with  the  intestinal  carcinoma. 

The  following  points  are  worthy  of  note:  Tenderness  on  deep  pres- 
sure over  the  sigmoid  flexure,  mucus,  bloody  stools  associated  with  great 
pain  and  tenesmus,  occasionally  involuntai*y  discharge  of  blood-colored 
mucus ;  meteorism  in  the  lower  abdominal  region.  From  the  primary 
focus  there  had  occurred  proliferation  into  the  left  iliac  vein,  and  subse- 
quently thrombosis  of  the  inferior  vena  cava. 

Worthy  of  note  are  the  arthritic  manifestations  in  both  wrist- joints, 
being  the  first  in  the  row  of  symptoms. 

At  no  time  were  there  symptoms  of  constriction ;  likewise  there  were 
absent  disturbances  on  part  of  the  stomach.     The  ascites  had  a  "milkv" 


274  TUMORS    OF    THE    ABDOMINAL    VISCERA 

character ;  there  were  found  extensive  retroperitoneal  glandular  metas- 
tases. 

Case  3. — J.  T.,  54  years,  M.    Silk  weaver. 

ad   1. — Mother  died   from   weakness   of  old   age. 
ad  5. — Was  always  healthy. 

ad  6. — In  September,  1899,  on  and  off  "wind  colic,"  relief  after 
discharge  of  flatus.  Stool  somewhat  retarded ;  after  bowel  movements, 
"pain  in  the  bowels."  Appetite  very  good.  About  July,  1900,  there 
began  continued  dull  pain  in  the  left  inguinal  region,  radiating  into  the 
left  testicle ;  the  left  testicle  and  left  spermatic  cord  became  painful  on 
pressure.  The  attending  physician  diagnosed  a  left-sided  varicocele. 
At  the  same  time  there  began  diarrhea  and  pain  in  the  anus ;  since  July, 
1900,  often  hourly  evacuation,  consisting  mostly  of  mucus;  after  bowel 
movement  great  feeling  of  fatigue.     Emaciation.     \o  pain  in  the  back. 

ad  7. — Face  pale  yellow,  somewhat  bloated.  On  the  left  side  above 
Poupart's  ligament,  particularly  on  intermittent  palpation,  a  tumor  as 
big  as  a  nut  can  be  felt,  painful  to  pressure. 

Per  rectum:  A  tumor  can  be  felt  high  up,  having  some  connection 
with  the  tumor  palpable  from  the  outside. 

Epigastrium  distended  as  a  result  of  great  enlargement  of  the  liver; 
the  left  lobe  in  particular  is  very  hard  and  uneven;  circumscribed  tender 
areas  on  the  upper  surface  of  the  liver.  Profuse  diarrhea,  subjective 
sensation  of  bowel  distention,  continued  bowel  noises. 

Feces:  Enormous  quantities  of  nmcus,  often  blood-colored. 

No  edemas,  often  profuse  night-sweats.  Ascites.  During  the  sub- 
sequent course  burning  at  urination,  the  last  portions  of  urine  being 
fecal;  gurgling  noises  during  urination  (discharge  of  flatus  per  ure- 
thram!).  Toward  the  end  severe  edema  in  the  lower  extremities  and  over 
the  sacrum. 

October  22:  During  the  night  sudden  pain  on  the  left  side,  above 
Poupart's  ligament,  together  with  great  tenderness  to  pressure  and 
much  tension;  severe  pain  in  the  lower  abdominal  region  when  sitting 
up.     Chill.     Pulse  very  small. 

October  23:  Erysipelatous  redness  over  the  painful  area  on  the  left 
side  below. 

October  25:  Exitus. 

ad  8.-^Beginning:  September,  1899. 

Status  presens :  September  -i,  1900. 
Autopsy:  October  26,  1900. 
Duration :  About  1  3'ear. 
ad  9.— Autopsy   (Hofrat  Professor  Dr.  A.   Welch selboum)  :  Car- 
cinoma in  the  sigmoid  flexure  with  perforation  into  the  bladder ;  metas- 
tases in  the  liver. 

Epicrisis:  The  appearance  of  flatulent  colic  should  always  put  us 
on  the  alert  for  a  possible  beginning  neoplasm  of  the  bowel ;  not  seldom 
this  is  the  first  manifestation  of  the  disease. 

In  the  beginning  there  was  mild  constipation,  with  a  feeling  of  internal 


CARCIN03IA    OF    THE    LARGE    INTESTINE  275 

pain  after  defecation  ;  only  about  two  months  prior  to  death  did  symp- 
toms of  a  deeply  seated  colon  disease  make  their  appearance :  frequent 
evacuations  of  small  quantities,  often  consisting  of  nmcus  only.  As  in 
left-sided  renal  neoplasms,  so  also  here  obstruction  to  the  venous  flow 
led  to  a  left-sided  varicocele  and  tenderness  to  pressure  in  the  left 
testicle.  Subsequently  occurrence  of  a  vesico-rectal  fistula  with  discharge 
of  flatus  per  urethram  during  urination,  accompanied  by  gurgling  noises. 

Case  4. — F.  V.,  65  years,  M. 

ad  2. — Mother  lived  over  TO  years. 

ad  3. — In  1857  had  typhoid  for  four  or  five  weeks. 

ad  4. — Bowels  always  regular,  one  movement  in  twenty-four  hours, 
"like  a  clock." 

ad  5. — Always  led  a  temperate  life ;  no  hemorrhoids ;  at  the  age 
of  46  had  icterus  for  3  weeks. 

ad  6. — In  January,  1900,  sudden  constipation  for  14  days,  bowels 
moving  at  intervals  of  five  days ;  stool  was  very  hard,  in  small  lumps. 
After  that  the  evacuations  again  became  regular,  there  being  no  com- 
plaints during  the  summer  of  1900.  Since  the  early  part  of  November, 
1900,  beginning  of  fluid  stools,  dark  in  color,  "clear  as  eggs,"  totalling 
up  to  twelve  stools  a  day,  the  individual  stool  small  in  quantity.  A  few 
minutes  before  the  stool  evacuation  takes  place  there  is  loud  rumbling 
coming  from  the  epigastrium  toward  the  symphysis.  Great  feeling  of 
thirst,  decrease  of  appetite,  eructation  after  meals.  No  appreciable 
emaciation.  Of  late  there  have  come  on  difficulties  in  urination,  viz., 
burning,  voiding  of  urine  possible  only  with  simultaneous  bowel  evacua- 
tion. No  pain  in  the  back,  no  colicky  pain.  Since  about  October,  1900, 
a  burning  sensation  is  experienced  on  the  left  side  deep  down  above  Pou- 
part's  ligament,  this  burning  being  somewhat  relieved  after  bowel  evacua- 
tions. The  inguinal  glands  on  the  left  side  arc  somewhat  tender  to 
pressure. 

ad  7. — A  freely  movable,  hard  tumor,  about  the  size  of  a  nut,  can 
be  felt  on  deep  palpation  above  Poupart's  ligament  on  the  left  side ;  no 
visible  peristalsis.  Dilatation  of  the  inferior  epigastric  vein.  Slight  re- 
tromalleolar  edema. 

February  9th :  Abdomen  very  tense,  especially  below  the  umbilicus,  in 
the  same  region  there  is  pain,  particularly  on  the  left  side.  Repeated 
chilliness,  nausea  and  vomiting,  very  small  pulse.  Continued  tenesmus. 
At  5  P.M.  sudden  death. 

ad  8.^ — Beginning:  January,  1900. 

Status  presens :  January  31,  1901. 
Autopsy:  February  11,  1901. 
Duration:  About  1  year,  1  month. 

ad  9. — Autopsy  (Professor  Dr.  //.  Albrccht)  :  Polypoid  and  in- 
filtrating adenocarcinoma  of  the  upper  portion  of  the  rectum  with  be- 
ginning ulceration  and  moderate  stenosis.  Great  dilatation  of  the  large 
bowel  with  hypertrophy  of  the  muscularis.    Beginning  peritonitis. 

Epicrisis:  In  view  of  the  "bowel  individuality"  of  the  patient  (stool 


276  TUMORS    OF    THE    ABDOMINAL    VISCERA 

regular  "like  a  clock")  we  may  assume  with  great  probability  that  the 
constipation  in  January,  1900,  lasting  for  14  days,  falls  within  the 
period  of  the  cancerous  disease  and  was  due  to  it. 

Hypertrophy  of  the  bowel  ahead  of  the  constriction  may,  in  the 
summer  of  1900,  have  compensated  for  the  obstruction. 

In  November,  1900,  the  symptoms  of  ulceration  appear  in  the  form 
of  frequent,  mucosanguineous  evacuations  accompanied  by  tenesmus. 

Such  manifestations  of  constriction  as  visible  peristalsis  and  colics 
are  absent  during  the  entire  course  of  the  disease.  The  burning  pain 
corresponding  in  location  to  that  of  the  tumor  and  which  let  up  some- 
what after  bowel  evacuation,  are  worthy  of  note. 

Case  5. — J.  H.,  57  years,  F.    Washerwoman. 

ad  3. — Never  had  any  diseases  of  childhood,  and  later  on  was  al- 
ways healthy. 

ad  4. — Bowel  movement  every  other  day  as  long  as  she  can  re- 
member. 

ad  6. — In  August,  1901,  the  patient  was  taken  sick  overnight  with 
violent  pain  in  the  abdomen,  there  being  four  or  five  nmcosanguincous 
stools  with  tenesmus  and  vomiting.  This  she  attributed  to  drinking  bad 
water.  The  blood  in  the  stools  was  fluid  and  red,  disappearing  after 
two  days,  after  which  only  large  quantities  of  mucus  were  discharged. 
The  attending  physician  diagnosed  the  case  as  "dysentery."  After  three 
weeks  the  patient  resumed  her  work  and  felt  cured. 

In  November,  1901,  likewise  in  February  and  April,  1902,  the  same 
painful  attacks  were  repeated  with  the  same  accompanying  manifesta- 
tions, lasting  from  2  to  3  days ;  the  attacks  of  pain  were  associated  with 
very  loud  bowel  noises.  In  the  intervals  the  bowel  movements  are  said 
to  have  been  normal  and  regular. 

In  May,  1902,  there  occurred  painful  attacks  of  a  colicky  character, 
accompanied  b}^  loud  bowel  noises. 

In  July,  1902,  there  was  no  bowel  movement  for  eight  days ;  subse- 
quently bowels  would  move  only  by  means  of  enemas.  The  attacks  of 
pain  grew  constantly  stronger  and  more  frequent.  Bowel  peristalsis 
became  visable. 

At  the  present  time  (November  11,  1902)  patient  says  she  has  had  no 
bowel  movement  for  15  days.  For  several  weeks  often  eructation,  odor- 
less; bitter  vomiting  after  larger  intake  of  food.  Appetite  would  be 
good,  but  by  way  of  precaution  the  patient  takes  only  milk,  red  wine  and 
soup.  Attack  of  pain  in  the  abdomen  diffuse  without  definite  point  of 
origin,  now  and  then  radiating  into  the  back,  increased  by  ingestion  of 
solid  or  liquid  food.  When  the  colicky  attack  is  at  its  height  several 
mouthfuls  of  biliary  fluid  are  vomited.  Bowel  noises,  especially  on  the 
right  underneath  the  costal  arch.  Nowhere  any  tenderness  to  pressure. 
The  colicky  pain  often  radiates  into  the  anus,  so  that  there  is  a  feeling 
as  if  the  bowels  would  have  to  move. 

ad  7.^ — Tongue  is  moist,  not  coated.     Abdomen  much  distended  by 


CARCIX0:MA    of    the    large    intestine  277 

mefcorism,  tension  often  beconjes  suddenly  increased  accompanied  by 
loud  intestinal  noises.  Tympanitic  resonance  over  the  liver  and  both 
loins.  Abundant  atelectatic  creaking  on  both  sides  over  the  lower  por- 
tions of  the  lungs.  Indication  of  retromalleolar  edema;  also  over  the 
sacrum.  No  appreciable  emaciation.  "Coffee-ground"  vomiting  with- 
out any  kind  of  vegetation   in   the  vomitus. 

Feces:  \eYy  small  lumps. 

ad  8. — Beginning:  August,  1901. 

Status  presens :  November  11,  1902. 
Operation:  November  19,  1902. 
Duration :  About  1  year,  3  months, 
ad  9. — Operation :   Carcinoma,   formed   like   a   signet   ring,   at   the 
sigmoid  flexure. 

Epicrisis:  In  this  case  the  first  clinical  symptoms  (intestinal  hemor- 
rhage, tenesmus,  pain)  were  attributed  to  dysentery.  According  to  the 
statement  of  the  patient  the  first  attack  (August,  1901)  was  accom- 
panied by  a  loss  of  blood  about  l/o  litre  in  quantity,  light  red  in  color; 
such  copious  hemorrhage  is  not  usually  associated  with  dysentery. 

The  intervals  between  the  single  attacks  which  were  free  from  com- 
plaints must  have  seemed  peculiar  and  naturally  easily  misleading.  The 
painful  attacks  with  their  characteristic  radiation  toward  the  anal  open- 
ing were  always  accompanied  by  loud  "rolling,"  this  being  an  important 
symptom  for  determining  their  origin. 

The  increasing  constriction  shows  itself  in  the  greater  intensity  and 
frequency  of  the  colicky  attacks,  occurrence  of  stubborn  constipation 
and  visible  peristalsis. 

There  occurs  also  regurgitation  per  os :  eructation,  biliary  vomiting 
when  the  painful  attacks  are  at  their  highest,  later  on  "coffee-ground" 
vomiting.-^ 

As  very  frequently  in  malignant  neoplasms,  so  also  here :  "Never  was 
sick,  nor  did  he  have  any  infectious  diseases  of  childhood." 

Case  6. — F.  W.,  44  years,  M.    Assistant  locksmith. 

ad   1. — Father  died  of  cancer  of  the  tongue,  mother  of  old  age. 

ad  3. — Twenty  3'ears  ago  had  S3'philis  (inunction  treatment)  ; 
neither  in  childhood  nor  adult  life  any  infectious  diseases. 

ad  6. — Since  about  January-,  1908,  rapid  loss  of  56  kg  in 
weight  (.'*).  For  the  past  six  months  bloody  diarrhea,  six  to  ten  times  a 
da}^  with  tenesmus.  Five  months  ago  is  said  to  have  had  peritonitis,  ac- 
companied by  severe  edema  of  the  legs.  Now  and  then  there  is  the  appear- 
ance of  a  swelling  on  the  left  side  above  Poupart's  ligament,  which  moves 
from  the  outer  side  to  the  middle.  Tenderness  on  pressure,  especially  in 
the  middle  of  the  lower  abdominal  region. 

ad  7. — A  tumor  can  be  felt  on  deep  palpation  in  the  lower  ab- 
dominal region,  uneven  and  sensitive  to  pressure.      Bloody  stools, 

"See  Splenic  Flexure,  1. 


278  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  8. — Beginning:  About  January,  1908. 
Status  presens :  October  28,  1908. 
Operation :  November  3,  1908. 
Autopsy:  November  8,  1908. 
Duration :  About  10  months. 
ad  9. — Finding  at   operation   (Primarius   Dr.   Fr.  Schopf)  :   Skin 
incision  from  the  umbilicus  to  the  symphysis.    At  the  promontory  one 
can  immediately  feel  a  hard  tumor,  as  big  as  a  man's  fist,  belonging  to 
the  sigmoid  flexure*. 

Autopsy:  (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Decomposing 
carcinoma  of  the  sigmoid  flexure. 

Epicrisis:  The  enormous  emaciation  (56  kg)  may  be  explained  by  the 
fact  that  this  patient  originally  was  of  pathologically  heavy  weight  due 
to  adiposity. 

Bloody  diarrhea  and  tenesmus  dominate  the  clinical  picture ;  it  seems 
that  once  during  the  course  of  the  disease  there  was  present  a  symptom 
complex  similar  to  that  of  peritonitis. 

The  patient  himself  claims  to  have  noticed  in  the  left  lower  quadrant 
a  swelling  moving  from  the  outer  side  to  the  middle  line.  Upon  examining 
the  patient  the  tumor  belonging  to  the  flexure  was  palpable  in  the  middle 
line  of  the  lower  abdominal  region. 

Case  7. — F.  H.,  50  years,  M.    Shoemaker. 

ad   1. — Mother  is  living,  75  3'ears  of  age. 

ad  3. — Measles  at  17,  had  pulmonary  catarrh  twice. 

ad  6. — In  January,  190-1,  pain  appeared  in  tlie  lower  abdominal 
region,  since  then  there  is  constipation ;  never  diarrhea.  The  attacks 
of  pain  are  cramp-like,  localized  on  the  left  side  and  extend  into  the 
lumbar  region ;  they  become  aggravated  with  increase  in  constipation. 
In  January  of  last  year  the  patient  had  to  urinate  very  often  ;  had  to 
hurry  every  time,  otherwise  could  not  retain  the  urine.  This  condition 
lasted  one  month.  Since  the  end  of  February  of  this  year  the  attacks 
of  pain  are  accompanied  by  visible  peristalsis  with  lively  "rolling"  in  the 
bowels.  Emaciation  to  the  extent  of  10  kg.  Attacks  of  pain  come  on, 
especially  when  the  bowels  have  not  moved  for  a  long  time;  they  are  also 
promptly  elicited  by  eating  bread  and  fermentable  foods ;  they  are  not 
accompanied  by  nausea  or  vomiting,  except  that  sometimes  there  is  sour 
eructation. 

ad  7. — Hard,  changeable,  fecal  tumors  can  be  felt  in  the  region  of 
the  sigmoid  flexure;  intestinal  peristalsis  with  protuberance  of  the  sig- 
moid flexure  which  collapses  immediately  after  discharge  of  flatus.  With 
spontaneous  distention  of  the  sigmoid  flexure  during  the  course  of  the 
peristalsis  the  left  inferior  epigastric  artery  beoomes  prominent.  In 
the  epigastrium  there  is  present  a  strange  reverberating  tympanitic 
sound.  No  tenderness  to  pressure  anywhere  in  the  abdomen.  Continued 
atelectatic  crepitus  over  the  left  lower  lobe.  No  edemas. 
Feces:  ^Nlacroscopically  no  mucus,  no  blood. 


CARCINOMA    OF    THE    LARGE    INTESTINE  279 

April   5:     Hiccough    for   some   days-      Beginnint^   of   tlie    peristaltic 
protuberance  always  in  the  left  half  of  the  epigastrium, 
ad  8. — Reginiiiiig:  January,   19()-4. 

Status  presens:  March  'I'l,  1904. 
Operation  :  April  7,  1904. 
ad  9. — Operation   (Docent  Dr.  A.  Exner):  Circular  constricting 
scirrhus   carcinoma   of  the   sigmoid   flexure,   as   big  as   a   walnut ;   freely 
movable.      No  metastases  demonstrable. 

The  tumor-masses  felt  in  the  flexure  were  feces,  the  carcinoma  itself 
had  not  been  palpable. 

Epicrisis:  ^'isible  peristalsis  is  preceded  by  attacks  of  colic,"  which 
undoubtedly  are  explained  by  the  beginning  constriction  and  are,  there- 
fore, to  be  looked  upon  as  constriction  colics.  They  are  located  more 
on  the  left  side,  radiate  toward  the  left  lumbar  region,  depend  on  the 
degree  of  constipation  and  are  influenced  in  an  alimentary  way  by  the  use 
of  fermenting  foods ;  on  and  ofl'  they  are  accompanied  by  sour  eruc- 
tation. 

These  constriction  colics  represent  the  first  symptom  of  the  disease. 
Simultaneously  there  appear  bladder  symptoms,  which  it  is  difficult  to 
interpret,  but  which  may  bo  looked  upon  as  symptoms  of  proximity. 

The  peristalsis  always  begins  in  the  left  half  of  the  epigastrium,  and 
in  the  course  of  it  the  sigmoid  flexure  stands  out  distinctly,  there  being 
at  the  same  time  engorgement  of  the  left  inferior  epigastric  vein.  Aside 
from  its  location  the  sigmoid  flexure  can  be  recognized  by  the  fact  of 
immediate  collapse  after  discharge  of  flatus. 

The  scirrhus  cicatricial  character  of  the  carcinoma  explains  both 
the  early  appearance  of  constriction  symptoms  and  the  lack  of  blood 
admixtures   in  the   stool. 

Case  8.— M.  F.,  52  years,  M. 

ad  3. — At  22  had  a  soft  chancre ;  otherwise  no  infectious  diseases. 

ad  4. — Always  had  a  good  appetite. 

ad  5. — Alwaj^s  enjoyed  the  best  of  health;  about  November,  1901, 
i.e.,  3  years  ago,  the  appetite  became  diminished;  there  set  in  an  itching 
of  the  skin ;  the  urine  became  darker.  He  felt  tired,  looked  bad,  the 
sclera?  showed  a  yellow  discoloration. 

During  the  winter  of  1902-1903  increase  of  these  manifestations. 
Lost  10  kg  in  weight.  Bowels  regular.  At  Karlsbad  the  jaundice  re- 
ceded somewhat,  appetite  improved,  the  itching  of  the  skin  became  less. 

ad  6. — Since  about  August,  1904,  feeling  of  tension  in  the  belly, 
stool  often  "lead  pencil-like' ;  discharge  of  mucus.  Defecation  is  often 
preceded  by  cutting  pain  about  the  umbilicus.  Frequent  bowel  noises 
beneath  the  left  costal  arch. 

ad  7. — Hemorrhagic  ascites ;  left  flank  somewhat  more  tense  than 
the  right.     Liver  enlarged  and  firm,  likewise  the  spleen. 
Urine:  Urobilinogen  very  abundant,  no  bilirubin. 

Blood:  4,400,000  erythrocytes,  7,600  leucocytes,  hemoglobin,  78%. 
Toward  the  end  severe  edema. 


280  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  8. — Beginning:  August,  190'i. 

Status  prescns :  November  26,  1904. 
Autopsy:  February  3,  1905. 
Duration :  About  6  months, 
ad  9. — Autopsy   (Professor  Dr.  A.  Ghon)  :  Ulcerating  carcinoma 
of  the   sigmoid   flexure  with   mild  stenosis,   secondary   carcinoma   of  the 
peritoneum   with   hemorrhagic   ascites.      Singly   scattered   carcinomatous 
nodules  in  the  liver.    Secondar}'  carcinoma  of  the  pleurae,  the  brain  and 
the  osseous  system.      Atrophic  cirrhosis  of  the  liver  and  chronic  splenic 
tumor.      Chronic  endarterites  deformans. 

Epicrisis:  The  history  of  the  disease  resolves  itself  into  a  longer 
period  belonging  to  the  cirrhosis  and  a  shorter  period  during  which  the 
cancerous  disease  exerts  its  influence.-' 

The  question,  whether  cirrhotic  processes,  either  by  way  of  a  dyscra- 
sia  or  through  circulatory  disturbances  in  the  bowel,  do  not  establish 
an  increased  predisposition  toward  cancer,  seems  to  me  worthy  of  further 
attention. 

The  following  could  be  interpreted  as  suspicious  of  an  intestinal  neo- 
plasm situated  low  down :  "Lead  pencil-like"  stools  with  copious  discharge 
of  mucus ;  very  lively  bowel  noises,  localized  and  having  a  metallic 
sound,  attacks  of  pain  before  bowel  evacuations,  left  flank  very  tense 
(dilatation  of  the  descending  colon!),  hemorrhagic  ascites  and  short 
course  of  same  (probably  3  months). 

Case  9.— M.  H.,  55  years,  M. 

ad   1. — Father  and  motlicr  died  at  a  very  old  age. 

ad  3. — No  infectious  diseases  in  childhood. 

ad  5. — Was  alwa3fs  healthy  and  strong. 

ad  6. — About  December,  1904,  general  weakness,  emaciation  and 
difficulty  in  breathing.  Since  the  beginning  of  the  disease  sluggish  bowel 
action,  no  diarrhea,  no  cramps.  In  January-,  1905,  the  abdomen  began 
to  enlarge,  but  without  pain.  Appetite  would  be  good  l)ut  the  patient 
is  afraid  to  eat  on  account  of  increasing  tenseness. 

ad  7. — Tongue  indented.  Liver  enormously  enlarged,  very  firm 
and  uneven ;  over  it  there  is  a  systolic  vascular  murmur ;  peritoneal  fric- 
tion over  the  left  lobe.  Dilatation  of  veins  over  the  epigastrium.  No 
ascites.  On  the  left  side  above  Poupart's  ligament  a  hard  resistance 
can  be  felt  on  intermittent  palpation.  Numerous  atheromas  on  the 
head  (developed  during  the  past  6  years).  Pupils  medium,  tardy  re- 
action to  light.  Edema  over  the  sacinim.  Findings  in  stool  are  nega- 
tive.    HCl  positive.     Leucopenia. 

April  28th :  Sudden,  very  violent  pain  in  the  belly,  collapse,  hemate- 
mesis  before  death. 

ad  8. — Beginning:  December,  1904. 

Status  presens:  April  17,  1905. 
Autopsy:  April  29,  1905. 
Duration :  About  5  months. 

"  See  Case  4,  page  275. 


CARCINOMA    OF    THE    LARGE    INTESTINE  281 

ad  9. — Autops}'  (Professor  Dr.  0.  Stoerk)  :  Carcinoma  at  the  pos- 
terior wall  of  the  sigmoid  flexure  (the  lower  part  of  same),  centrally 
perforated  toward  the  pouch  of  Douglas.  Circumscribed  purulent  peri- 
tonitis in  the  true  pelvis  and  a  recent  diffuse  peritonitis.  Enormous 
metastases  in  the  liver  (weight  of  liver  10.7  kg). 

Epicrisis:  As  so  frequently:  Longevity  of  the  parents,  the  patient 
himself  always  having  been  well. 

Aside  from  the  terminal  perforating  peritonitis  the  primary  car- 
cinoma runs  its  course  practically  without  symptoms. 

Besides  the  proniinent  appearance  of  cachexia  there  stand  in  the  fore- 
ground the  metastases  in  the  liver  which  lead  to  the  enormous  hepatic 
enlargement.     Appetite  is  well  conserved,  HCl  secretion  persists. 

E.    Rectum 

Case  1.— M.  A.,  59  years,  M.    Tailor. 

ad  1. — Mother  suffering  from  some  pulmonary  disease,  father  died 
at  84<. 

ad  5. — Six  years  ago  suppuration  started  in  three  places  over  the 
sternum,  associated  with  severe  cough  and  night-sweats ;  the  process 
lasted  three  years. 

ad  6. — Since  November,  1899,  diarrhea  (8-12  stools  a  day)  with 
copious  discharge  of  mucus.  In  December,  1899,  short  breath  on 
mounting  stairs  and  rapid  walking.  Since  May,  1900,  attacks  of  dizzi- 
ness, swelling  of  the  lower  extremities.      No  abdominal  pain. 

ad  8. — Ascites.  Continued  diarrhea  with  incontinence  (tannalbin 
given  hourly,  without  effect).  Toward  the  end  considerable  pale  edema 
of  the  lower  extremities. 

Feces:  Fluid,  very  rich  in  mucus. 

Urine:  Urobilinogen  very  strongly  positive.     Afebrile  course. 

ad  8. — Beginning:  November,  1899. 

Status  presens:  May  20,  1900. 

ad  9. — Autopsy  (Docent  Dr.  K.  Landsteiner)  :  Ring-shaped  rectal 
carcinoma,  ulcerating  in  many  places,  beginning  8  cm  above  the  anus, 
with  extensive  metastases  in  the  liver;  pulmonary  metastases.  Multiple, 
ring-shaped  tubercular  ulcers  of  the  small  and  large  intestine.  Bilateral 
induration  of  the  pulmonary  apices.  Ascites,  anasarca.  Perirectal  sup- 
puration, beginning  peritonitis. 

Epicrisis:  The  caries  of  the  sternum  and  the  induration  of  the  pul- 
monary apices  during  life  had  suggested  tubercular  intestinal  ulcers  as 
the  cause  of  the  bowel  symptoms,  and  these  were  actually  also  found  at 
autopsy.  But  outside  of  that  there  also  existed  an  ulcerating  carcinoma. 
Referable  to  the  latter  were  the  following:  Particular  frequency  of  the 
stools,  occasional  incontinence,  evacuation  of  very  copious,  colloid-like 
masses  of  mucus,  and  the  appearance  of  severe  edema  in  the  lower  ex- 
tremities. The  large  quantity  of  urobilinogen  might  have  some  con- 
nection with  the  metastases  in  the  liver. 


282  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  2.— W.  J.,  64  years,  M. 

ad   1. — Parents  long  lived. 

ad  3. — No  infectious  diseases,  neither  in  childhood  nor  later, 
ad  4. — Stool  always  perfectly  regular, 
ad  5. — Always  healthy,  never  was  sick. 

ad  6. — Since  August,  1899,  two  to  three  bowel  movements  daily. 
In  January  1900,  severe  night-sweats,  so  that  a  change  of  shirts  was 
often  necessary ;  no  cough,  no  fever. 

Since  March,  1900,  one  fluid  bowel  evacuation  every  two  to  three 
hours;  bloody  colored  mucus  discharged  in  small  quantities  accompanied 
by  violent  tenesmus;  now  and  then  bowel  incontinence.  Appetite  became 
diminished. 

In  May,  1900,  extraordinary  feeling  of  weakness. 

Since  the  beginning  of  June  of  this  year  (1910)  edema  of  the  lower 
extremities.  No  vomiting,  no  eructation.  All  foods  are  well  tolerafted, 
diet  has  no  influence  on  the  diarrhea.  Urine  comes  after  prolonged 
straining.      No  pain  in  the  back. 

ad  7. — No  cachectic  appearance.  Tongue  dry  over  its  middle  por- 
tion. Liver  enlarged,  very  firm,  having  flat  nodules  on  the  surface,  not 
any  appreciable  tenderness  on  pressure.  Severe  edema  of  the  leg  below 
the  knee  and  over  the  sacrum.  Now  and  then  temperature  up  to  38°  C. 
After  enemas  of  water  there  is  prolapse.  Ampulla  very  wide ;  a  circular 
cancer  mass  can  be  felt  at  the  promontory. 

Blood:  4,000,000  erythrocytes,  7,000  leucocytes,  50%  hemoglobin. 
Feces:  Large  quantity  of  blood-streaked  mucus. 

Toward  the  end  sudden  pain  over  the  symphysis  with  feeling  of  heat 
and  sweat-covered  brow  and  great  sensation  of  tension  in  the  belly  when 
lying  on  the  right  or  left  side. 

ad  8. — Beginning:  August,  1899. 

Status  presens:  June  12,  1900. 
Autopsy:  July  4,  1900. 
Duration:  About  11  months, 
ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Papillary  ring-shaped 
carcinoma  of  the  rectum  with  constriction ;  a  smaller  papillary  carcinoma 
above  the  first.     Polyposis  of  the  bowel.     Dilatation  of  the  large  bowel, 
the  bowel  wall  being  separated  in  places  and  perforating  into  the  sig- 
moid flexure.     Putrid  diffuse  peritonitis.     Secondary  carcinoma  of  the 
liver. 

Epicrisis:  Longevity  of  the  parents!  Has  had  no  disease!  Tenes- 
mus and  occasional  incontinence  at  an  advanced  age  must  always  remind 
us  of  rectal  cancer  and  demands  a  most  careful  digital  examination,  even 
when,  as  in  this  case,  the  appearance  of  the  patient  is  good. 

If  we  are  dealing  with  individuals  who  all  their  life  have  had  regular 
bowel  movements,  the  appearance  of  bowel  irregularities  must  always 
cause  us  to  look  for  intestinal  cancer. 

Profuse  night-sweats  may  also  be  explained  by  carcinomatous  disease. 
The  copious  bowel  evacuations  due  to  rectal  cancer  cannot  be  influenced 
by  diet  or  astringents. 


CARCINOMA    OF    THE    LARGE    INTESTINE  283 

Case  3. — J.  A.,  36  years,  M.    Foreman. 

ad  1. — Mother  lives  and  is  hefllthy,  likewise  four  brothers  and 
sisters. 

cid  2. — From  childhood  until  July,  1899,  averaged  one  nose-bleed 
every  two  weeks. 

ad  -it. — Appetite  poor  as  long  as  he  can  remember, 
ad  5.- — Two  years  ago  the  patient  began  to  vomit  every  morning 
after  his  coffee;  this  kept  on  for  almost  one  year. 

ad  6. — In  February,  1900,  constipation  set  in,  intestinal  colic  and 
vomiting  after  every  intake  of  food;  the  appetite  diminished.  In  April, 
1900,  the  vomiting  ceased,  the  appetite  is  said  to  have  improved  after 
taking  nux  vomica,  cinchona  bark  and  soda  bicarbonate.  Never  any 
diarrhea.     During  the  past  weeks  frequent  prolapse  of  the  rectum. 

Since  the  latter  part  of  August,  1900,  the  patient  complains  of 
pressure  and  fulness  in  the  region  of  the  stomach;  on  account  of  this 
feeling  of  pressure  he  cannot  eat  much;  the  liver  is  said  to  have  become 
larger. 

Since  February,  1900,  lost  15  kg  in  weight.  Pain  in  the  back  only 
after  lying  down  for  a  longer  time. 

Severe  pain  in  the  back  from  the  top  of  the  scapula  to  the  costal 
arches.    No  exacerbation  on  motion,  decrease  after  defecation. 

ad  7. — Face  color,  pale  yellow.  Liver  enormously  enlarged,  hard, 
uneven,  not  tender  on  pressure.  Dilated  veins,  crossing  the  right  costal 
arch.  Distinct  ballottcment  of  the  liver.  Ascites;  severe  retromalleolar 
and  scrotal  edema.  Atelectatic  crepitation  over  the  right  lower  lobe 
of  the  lung. 

Feces:  Bowel  movements  fairly  regular,  containing  large  quantities 
of  mucus. 

Urine:  No  bilirubin. 

Rectum:  About  8  cm  above  the  anal  opening  there  is  a  protruding 
hard  tumor  with  an  opening  which  admits  the  introduction  of  one  finger. 
Now  and  then  temperature  elevation  up  to  38°  C. 
ad  8. — Beginning:  February,  1900. 

Status  presens:  September  10,  1900. 
Autopsy:  October  13,  1900. 
Duration:  About  8  months, 
ad  9. — Autopsy   (Professor  Dr.  H.  Albrecht)  :  About  8  cm  over 
the  anus  there  is  a  small,  moderately  constricting  carcinoma  with  enor- 
mous metastases  in  the  liver  (weight  8,700  g).     The  vena  cava  and  por- 
tal  vein   are   free.     Edema   of   the   lower   extremities    and   the   scrotum. 
Hemorrhagic  erosions  in  the  stomach. 

Epicrisis:  The  tendency  to  epistaxis  deserves  mention  as  a  constitu- 
tional peculiarity;  during  the  cancerous  period  it  ceased.  Constipation, 
intestinal  colic  and  vomiting  count  among  the  initial  symptoms. 

The  pain  in  the  back  is  decreased  after  bowel  movements,  and  are 
independent  of  motion. 

The  epigastric  symptoms  occurring  during  the  later  course  of  the 
disease  (feeling  of  pressure,  etc.)  are  due  to  the  metastases  in  the  liver. 


28^  TUMORS    OF    THE    ABDOMINAL    VISCERA 

In  addition  to  ascites  there  is  present  severe  edema  of  the  legs  and  the 
scrotum.  • 

Case  4.— J.  R.,  60  years,  M. 

ad  6. — Since  about  April,  1908,  profuse  diarrhea,  now  and  then 
vomiting;  emaciation  since  about  August,  1908.  Transient  icterus  in 
the  course  of  the  disease. 

ad  7. — Liver  greatly  enlarged,  hard,  uneven.  An  ulcerating  can- 
cer can  be  felt  through  the  rectum. 

ad  8. — Beginning:  About  April,  1908. 

Status  presens:  October  23,  1908. 
Autopsy:  November  11,  1908. 

ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Gela- 
tinous carcinoma  in  the  rectum.  Multiple  metastases  in  the  liver 
(3,770  kg). 

Case  5.— L.  N.,  49  years,  M. 

ad   1. — Parents  arc  healthy. 

ad  4. — Bowels  always  perfectly  regular. 

ad  5. — Was  always  healthy. 

ad  6. — Since  about  January,  1907,  very  stubborn  constipation, 
occurring  H})parently  without  cause  and  M'ithout  any  cliangc  in  the  mode 
of  living.  During  a  stay  in  the  country  in  the  summer  of  1907  the  bowels 
again  became  regular.  During  the  past  year  has  lost  10  kg  in  weight. 
Appetite  very  good,  no  eructation,  no  vomiting.  At  present  (January, 
1908)  again  constipation  ;  bowels  move  only  after  taking  phenolphthalein  ; 
Avithout  cathartics  there  is  often  no  bowel  movement  for  five  days.  De- 
spite constipation  there  is  now  and  then  tenesmus  with  involuntary  bowel 
movements ;  this  happened  twice  during  the  past  year.  On  and  off  dis- 
charge of  some  nuicus  and  blood.  Pmemas  arc  not  retained.  No  colics, 
no  sensations  of  metcorism.  On  and  off  pain  in  the  region  of  the  sacrum. 
A  surgical  examination  made  in  1907  yielded  negative  results. 

ad  7. — Carcinoma  projecting  into  the  ampulla  with  very  narrow 
lumen  (January  14,  1908). 

ad  8. — Beginning:  About  January,  1907. 
Status  presens:  January  14,  1908. 
Operation:  January,  1908. 

ad  9. — Operation  (Hofrat  Professor  Dr.  J.  Hochenegg)  :  Car- 
cinoma of  the  rectum ;  total  extirpation  no  longer  feasible. 

Epicrisis:  The  patient,  who  at  the  time  of  my  examination  (January 
14,  1908)  Avas  still  fulfilling  the  duties  of  his  strenuous  occupation  as  a 
court  officer,  gave  so  typical  a  history  that  even  before  the  rectal  exam- 
ination the  diagnosis  could  be  made  almost  with  certainty. 

Particularly  Avorthy  of  note  is  the  contrast :  stubborn  constipation 
<'ind  Avith   it   occasional   incontinence !     The  isolated  discharge   of  blood 
and  mucus  is  also  abvays  highly  suspicious  of  an  ulceration  Ioav  down. 
It  is  easilv  seen  AA'hy  enemas  are  not  retained  when  there  is  an  ob- 
struction   loAv   doAvn    in    the   boAvcl.       I^naccountable    constipation    AA^here 


CARCINOMA    OF    THE    LARGE    INTESTINE  285 

formerly  the  bowels  were  regular  ought  ahva^-s  to  bring  to  mind  the  pos- 
sibility of  a  gastric  or  intestinal   cancer. 

It  is  strange  that  pal})ati()n  made  by  a  very  competent  surgeon  in 
August,  1907,  yielded  a  negative  result.  It  is  probable  that  at  that 
time  the  tumor  was  high  up,  whereas  at  the  time  of  my  examination  it 
liad  been  displaced  downward. 

Case  6.— J.  W.,  61  years,  M. 

ad  3. — No  infectious  diseases, 
ad  4. — Bowels  always  regular,  appetite  good. 

ad  6. — About  March,  1901,  beginning  of  fatigue  and  general 
malaise. 

End  of  March,  1901 :  Mild  abdominal  colic  two  or  three  times  a 
month,  mostly  toward  6  p.m.  Diffuse  pain,  not  very  severe,  some  radia- 
tion toward  the  anus,  accompanied  by  lively  noises. 

Toward  the  end  of  jNIay,  1901,  constipation  began. 

From  July  to  October,  1901,  the  patient  is  said  to  have  been  treated 
with  poultices  for  a  swelling  on  the  left  side  above  Poupart's  ligament 
(fecal  tumors?).  Stool  mostly  hard,  thick  as  a  small  finger.  After 
taking  cathartics  (bitter  Avaters)  there  is  often  blood  and  mucus  in  the 
stool,  blood  partly  clotted,  partly  fluid.  In  the  beginning  of  ^March,  1902, 
about  three  quarts  {?)  of  light  red  blood  are  said  to  have  been  discharged. 
The  bowel  movements  are  said  to  have  become  regular  for  a  time,  on  a 
milk  diet,  while  staying  in  the  country.  Loss  in  weight  '20  kg,  increasing- 
pallor  and  fatigue.     No  pain  in  the  back. 

ad  7. — Tongue  dry.  Visible  peristalsis  with  very  wide  loops  of  gut, 
splashing  especially  in  the  flanks,  lively  bowel  noises.  Ascites,  no  edemas. 
Hemoglobin,  30%. 

Per  rectum:  Firm  tumor,  easily  reached,  cauliflower-like,  projecting 
into  the  lumen  with  a  central  opening. 

ad  8. — Beginning:  About  March,  1901. 
Status  presens :  March  17,  1902. 

Epicrlsis:  Intestinal  colics,  occurring  periodically  two  to  three  times 
a  month,  usher  in  the  clinical  picture.  They  deserve  attention,  the  more 
so  as  we  are  dealing  with  an  individual  previously  possessing  a  sound 
stomach  and  bowel.  Radiation  of  the  colicky  pain  toward  the  anus 
must  always  suggest  a  deep-seated  intestinal  process  as  the  cause  of  same. 
As  a  result  of  copious  hemorrhage  from  the  ulcerating  tumor  severe 
anemia  has  supervened  (30%  hemoglobin). 

In  this  instance  the  cancer  had  led  to  exquisite  manifestations  of 
constriction  with  visible  peristalsis ;  there  were  splashing  zones  in  the 
flank  corresponding  to  the  dilated  colon. 

Case  7.— F.  G.,  61  years,  M. 

ad  2. — For  several  years,  especially  in  winter,  pain  in  the  knee 
and  ankle  joints,  without   fever. 

ad  3. — ]Meas]cs  at  9;  at  30  had  a  left-sided  pneumonia.. 

ad  6. — In  April,  1904,  without  apparent  cause,  violent  tenesmus,. 


286  TUMORS    OF    THE    ABDOMINAL    VISCERA 

there  being  up  to  16  evacuations  a  day,  consisting  mostly  of  bloody 
mucus.  It  is  said  that  "catarrh"  was  diagnosed,  the  disease  being  at- 
tributed to  the  existing  hemorrhoids.  Even  at  that  time  there  was 
present  loud  "rolling"  in  the  abdomen.  Appetite  much  diminished,  later 
on  disgust  toward  meat.  In  the  evening  frequent  mild  febrile  movements 
accompanied  by  sensations  of  heat  and  cold.  Severe  emaciation  and 
feeling  of  weakness.     No  pain  in  the  back. 

ad  7. — Face  full,  reddened ;  no  cachectic  discoloration.  No 
edemas. 

Feces:  Bloody  mucous  masses. 

Rectal  finding:  Typical  portio-like  projecting  rectal  cancer, 
ad  8. — Beginning:  April,  1904. 

Status  presens:  March,  1905. 
Duration:  About  1  year. 

Epicrisis:  The  severe  tenesmus  accompanied  by  bloody  mucous  evac- 
uations and  loud  inimbling  in  the  bowels  should  have  led  to  the  right 
diagnosis  in  April,  1904).  Unaccountable  appearance  of  gastro-intes- 
tinal  disturbances  always  deserves  most  serious  consideration  with  refer- 
ence to  the  possibility  of  a  malignant  neoplasm.  As  is  not  seldom  the 
case  in  malignant  diseases,  so  also  here  there  exists  "rheumatic"  ante- 
cedents, namely,   recurring   afebrile   arthridites. 

Good  facial  appearance  with  fulness  and  a  red  color  is  frequently 
met  with  precisely  in  connection  with  rectal  cancer  and  is  probably  due 
to  the  fact  that  with  good  appetite  there  is  a  good  absorption  of  food, 
often  for  a  long  time. 

Case  8.— F.  R.,  13  years,  F. 

ad  1. — Parents  are  healthy, 
ad  3. — Has  had  no  infectious  diseases. 

ad  6. — About  December,  3904,  colicky  pain  appeared  in  the  abdo- 
men, bowels  became  constipated.     The  appetite  was   always   good. 

January,  1905:  Enlargement  of  the  right  side  of  the  abdomen  and 
later  of  the  entire  belly;  no  appreciable  emaciation.  Of  late  continuous 
diarrhea.     Pain  in  the  region  of  the  sacrum. 

ad  7. — Dulness  and  hard  tumor-masses  in  the  ileocecal  region,  simi- 
lar hard  uneven  tumor-masses  in  the  left  half  of  the  abdomen.  Liver  is 
hard  and  enlarged.  Friction  can  be  felt  in  the  right  half  of  the  abdomen. 
Belly  very  tense  and  distended ;  extensive  venous  dilatations  over  the 
middle  of  the  epigastrium.  External  glands  not  affected.  Edema  in 
the  lower  extremities  and  over  the  sacrum. 

Blood:  3,400,000  erythrocytes,  13,200  leucocytes,  557^  heiiioglobin. 
Urine:  No  aldehyde  reaction. 

ad  8. — Beginning:  About  December,  1904. 
Status  presens:  INIarch  18,  1905. 
Autopsy:  April  3,  1905. 
Duration :  4  months, 
ad  9. — Autopsy   (Professor  Dr.  A.  Ghon)  :  Medullary  malignant 
tumor  of  the  rectum  in  its  upper  part  with  ulceration  in  form  of  several 


CARCINOMA    OF    THE    LARGE    INTESTINE  287 

imislirooin-sliapt'd  lur^c  iiodulcs  uloiig^side  of  cucli  other.  Secondary 
tumors  in  the  lyniph-ghinds,  as  also  in  tlie  mesocolon,  encroaching  on  the 
posterior  wall  of  the  uterus.     Two  large  metastases  in  the  liver. 

Histological  finding:  Alveolar  sarcoma. 

Epicrisis:  Here  we  have  sarcoma  of  the  rectum  in  a  13-year-old  girl. 
It  began  with  colics  and  tendency  to  constipation ;  during  the  latter 
period  continuous  diarrhea.  The  whole  lower  abdomen  was  filled  with 
tumors,  so  that  one  would  not  be  naturally  led  to  suspect  a  neoplasm 
originating  in  the  rectum.  The  epigastric  venous  dilatations  were  ex- 
plained by  the  extensive  metastases  in  the  liver;  urobilinogen  was  not 
demonstrable  in  the  urine. 


Case  9.— M.  P.,  60  years,  M. 

ad  1. — Father  died  at  76  from  weakness  of  old  age,  mother  died 
of  gastric  cancer  at  78. 

ad  3. — Twenty-four  years  ago  acquired  syphilis. 

ad  5. — Otherwise  always  healthy. 

ad  6. — In  March,  1903,  there  began  attacks  of  colic  in  the  lower 
abdominal  region.  They  were  usually  ushered  in  by  "running  together 
of  salty  water  in  the  mouth,"  after  which  there  appeared  loud  bowel 
noises,  the  belly  became  tense,  pain  being  somewhat  more  severe  in  the  left 
lower  abdominal  region,  and  often  there  occurred  vomiting  of  yellowish 
masses ;  the  attacks  concluded  with  a  discharge  of  dark  fluid  stools,  after 
which  there  was  immediate  relief;  At  the  start  such  attacks  occurred 
but  once  in  two  months,  later,  however,  became  more  frequent.  About 
nine  weeks  ago,  toward  the  end  of  January,  1905,  there  occurred  another 
such  attack,  but  not  particularly  violent,  followed  by  icterus  which  per- 
sists to  the  present  time.  Appetite  was  fairly  good  until  the  appearance 
of  icterus.  Never  any  mucus  or  blood  in  the  stool.  Of  late  great  fatigue 
and  insomnia. 

ad  7. — Liver  enlarged,  hard,  uneven  ;  over  it  there  can  be  heard  a 
loud  systolic  murmur,  especially  toward  the  end  of  expiration.  Icterus 
of  medium  intensity.  Tenderness  to  pressure  on  the  left  side  above  Pou- 
part's  ligament.  Dilated  veins  in  the  epigastrium.  Severe  retromalleo- 
lar  edema. 

Feces:  Abundance  of  soap  needles,  otherAvise  nothing  unusual.     Two 
to  three  bowel  movements  daily. 

ad  8. — Beginning:  About  March,  1903. 
Status  prcsens :  March  27,  1905. 
Autopsy:  April  13,  1905. 
Duration :  About  2  years. 

ad  9.- — Autopsy  (Docent  Dr.  K.  Landsfeiner)  :  Carcinoma  of  the 
lectum  high  up,  ring-shaped  ulceration.  Metastases  in  the  liver,  with 
perforation  in  the  cystic  duct  and  ductus  choledochus,  together  with  oc- 
clusion of  same  by  a  soft,  large  tumor  nodule.  Severe  icterus.  Ob- 
solete tuberculosis. 

Epicrisis:  The  attacks  of  colic  occurring  in   ]March.   1903,  i.e.,  two 


288  TUMORS    OF    THE    ABDOMINAL    VISCERA 

years  prior  to  death,  were  the  first  clinical  manifestations  of  the  car- 
cinoma. Their  situation  in  the  lower  abdominal  region,  accompanied  by 
loud  rumbling  in  the  bowels  and  distention  of  the  abdomen  sufficiently 
characterized  them  as  intestinal  colics  and  as  constriction  colics  in  par- 
ticular, so  that  even  the  icterus  accidentally  occurring  after  one  of  these 
attacks — the  same  as  after  a  gall-stone  colic — could  not  dissuade  us 
from  the  first  opinion.  The  more  left-sided  localization  of  the  colics  ac- 
companied by  tenderness  on  pressure  at  that  place  seems  very  worthy  of 
note  as  it  corresponds  to  the  seat  of  the  disease. 

Remote  symptoms  accompanying  the  attacks  were  a  sort  of  sali- 
vation (regurgitation  from  the  stomach?)  and  occasionally  also  vomiting. 
The  appetite  remained  undisturbed  for  a  long  time. 

The  stools  in  this  case  offered  no  clue  to  a  carcinoma  of  the  rectum. 

The  dilated  veins  in  the  epigastrium  pointed  to  an  obstruction  in 
the  portal  circulation  which  was  found  to  be  due  to  extensive  cancer 
metastases.  These  also  gave  occasion  for  the  occurrence  of  a  sj^stolic 
vascular  murmur  over  the  liver. 


Case  10. — A.  R.,  59  years,  M. 

ad  3. — Contracted  syphilis  at  28 ;  otherwise  no  infectious  diseases. 

ad  5. — Was  always  healthy,  strong  and  well  nourished.  Five  years 
ago  (1900)  the  patient  noticed  that  drops  of  his  urine  falling  on  dark 
trousers  left  stains.  He  became  emaciated,  felt  weak,  had  severe  thirst ; 
on  his  left  forearm  there  developed  a  phlegmon,  and  after  an  alxlominal 
massage  multiple  abscesses  made  their  appearance  in  the  abdominal 
skin.  Following  this  6%  sugar  was  found  in  the  urine.  In  June,  1903, 
there  was  2.5%. 

ad  6. — For  the  past  year  and  a  half  (about  iNIay,  1904*)  the  bowels 
were  irregular,  the  patient  often  had  to  take  cathartics,  and  during  the 
last  half  year  these  were  required  daily.  When  the  bowels  do  not  move 
for  some  length  of  time  there  ensues  eructation  and  vomiting  of  bile, 
which  symptoms  disappear  immediately  after  the  bowels  have  moved. 
About  JNIay,  1905,  for  the  first  time  there  was  a  discharge  of  clotted 
blood  after  sudden  tenesmus  had  set  in  during  the  night ;  since  then  fre- 
quent discharge  of  clear  blood  or  blood  mixed  with  feces.  Burning  in 
the  rectum.  Since  the  middle  of  September,  1905,  two  to  three  bloody 
stools  a  day.  Before  each  bowel  movement  there  are  severe  cramp-like 
pains  about  the  navel,  radiating  into  the  region  of  the  bladder  and  ac- 
companied by  tenesmus.  After  eating  a  roll  or  a  dumpling  the  abdomen 
becomes  greatly  distended  and  there  are  present  cramp-like  pains  in  the 
lower  part  of  the  belly.  Appetite  good.  Of  late  frequent  very  loud 
rolling  in  the  belly. 

ad  7. — Sallow  face  color.    Liver  enlarged,  hard,  somewhat  uneven. 
Subfebrile  temperatures,  often  above  37°   C.    No  edemas. 
Rectal  finding:  Ulcerating  fixed  carcinoma. 
Feces:  INIuco-sanguineous,  strongly  alkaline. 


CARCINOMA    OF    THE    LARGE    INTESTINE  289 

Urine:  No  sug'ar,  not  even  after  eatin<;-  50  g  wliite  bread, 
ad  8. — Beginning:  About  May,  1904. 

Status  prcsens:  October  4,  1905. 
Duration:  About  1^2  yc^rs. 
ad  9.- — Diagnosis:   Rectal  carcinoma  and  metastases   in   the  liver; 
diabetes  mellitus   (latent). 

Epicrisis:  Gradually  increasing  constipation  counts  among  the  ini- 
tial manifestations  of  the  disease ;  exacerbations  of  same  are  accompanied 
by  gastric  symptoms,  such  as  eructation  and  biliary  vomiting. 

During  the  subsequent  course  there  follow  tenesmus,  discharge  of 
blood  and  colics  in  the  lower  abdomen,  which  precede  bowel  movements. 
Diabetes  mellitus  was  recorded  in  the  history;  at  the  time  of  the  examina- 
tion the  urinary  finding  was  negative. 

Case  11.— W.  R.,  49  years,  M.    Miller. 

ad  3. — During  1878,  while  in  Bosnia,  had  malaria  for  over  a  half 
year ;  otherwise  has  had  no  infectious  diseases. 

ad  4. — Formerly  the  bowels  were  regular ;  had  hemorrhoids. 

ad  6. — Since  about  July,  1905,  frequent  evacuations,  often  ten 
times  a  day ;  since  then  there  are  also  night-sweats.  Appetite  always 
good,  no  vomiting.  For  the  past  four  weeks  insomnia,  has  lost  20  kg  in 
weight  during  the  past  few  weeks.  Of  late  distention  of  the  lower  ab- 
dominal region ;  dorsal  decubitus  only  is  tolerated,  lying  on  either  side 
is  painful.  Stools  always  dark,  often  containing  rather  large  quantities 
of  mucus.  For  the  past  fourteen  days  there  are  gurgling  noises  at  the 
end  of  urination  "as  if  from  wind."  No  pain  in  the  back.  Tenderness 
on  pressure  in  the  inferior  abdominal  region.  Pain  toward  the  end  of 
stool  evacuations,  radiating  into  the  left  testicle. 

ad  7. — Pale  yellow  face  color,  inferior  abdominal  region  much  dis- 
tended and  rigid.  No  edemas.  Mildly  febrile  course  with  temperature 
rises  up  to  38°  C. 

Feces:  Fluid,  much  mucus;  contain  pus  cells  and  erythrocyte 
shadows. 

Urine:  Pyuria  with  intestinal  flora;  muscle  fibres   in  the  sediment! 
Subjectively  there  is  slight  tenesmus,  slight  burning  at  urination. 
Blood:  9,400   leucocytes. 

liectoscopic  examination:  Ulcerating  carcinoma  on  the  anterior  wall, 
situated  at  the  juncture  of  the  rectum  and  sigmoid  flexure,  occupying 
two-thirds  of  the  circumference. 

ad  8.- — Beginning:  About  Jul}^,  1905. 

Status  presens:  December  12,  1905. 

ad  9. — Diagnosis:  High  up  ulcerating  cancer  of  the  rectum  with 
vesical  fistula. 

Epicrisis:  In  this  case  the  rectal  cancer  runs  its  course  with  very  fre- 
quent mucous  evacuations  from  the  start.  Worthy  of  note  are  the  pains 
associated   with   bowel    movements    and   radiatins;   into   the   left    testicle. 


290  TUMORS    OF    THE    ABDOMINAL    VISCERA 

The  history  itself  (gurgling  noises  during  the  act  of  urination)  permits 
us  to  assume  a  recto-vesical  fistula,  the  existence  of  which  is  confirmed 
by  the  findings  in  the  sediment  (intestinal  flora  and  muscle  fibres). 

The  subjective  bladder  symptoms  are  slight.    Night-sweats  are  pres- 
ent among  the  initial  symptoms. 


Case  12. — J.  N.,  66  years,  M.    Locksmith. 

ad   1. — Father  died  at  60,  mother  at  82  3'ears  of  age. 

ad  2. — In  lOOJ^  had  rheumatic  pains  in  the  shoulders,  particularly 
the  right. 

ad  3. — Has  not  had  any  infectious  diseases. 

ad  4. — Bowels  were  always  regular. 

ad  5. — Was  always  strong  and  healthy.  Claims  that  eight  years 
ago  he  once  noticed  blood  in  the  stool  toward  the  end  of  defecation. 

ad  6. — Two  weeks  before  Christmas  of  1905  the  present  illness 
began  with  severe  pain  in  the  region  of  the  left,  later  also  the  right 
clavicle,  the  pain  extending  downward  to  the  abdomen ;  stabbing  pains 
on  breathing.  Right  lateral  position  provoked  pain  on  the  left  side  and 
vice  versa.  On  sitting  up  there  were  very  severe  pains  in  the  back,  also 
pain  anteriorly  in  the  right  thigh.  If  the  patient  urinates  without  having 
previously  emptied  the  bowels  the  stool  and  urine  are  discharged  simul- 
taneously. Bowel  evacuations  are  copious,  several  times  a  day ;  often 
distention  due  to  metcorism.  Appetite  always  good,  even  for  meat.  Pain 
in  the  back  on\y  when  sitting  up.  Flexion  of  the  right  thigh  on  the  ab- 
domen is  painful,  and  therefore  the  patient  brings  up  the  thigh  with  his 
hand. 

ad   7. — IJver  much  enlarged,  firm,  uneveii.      Slight  ascites,  traces 
of  edema  behind  the  malleolus  and  at  the  sacrum.    HCl  positive. 
Feces:  Bloody,  clear  as  eggs. 
Blood:  10,800  leucocytes. 
Rectal  finding:  Typical  rectal  carcinoma. 

ad  8.^ — Beginning:  December,  1905. 

Status  presens :  February  27,  1906. 

ad  9. — Diagnosis :  Carcinoma  of  the  rectum ;  metastases  in  the 
liver. 

Epicrisis:  Worthy  of  note  is  tlie  latent  course  of  the  rectal  cancer  until 
the  appearance  of  metastases  in  the  liver  which,  on  account  of  distention 
of  the  capsule,  lead  to  radiations  of  pain  as  far  distant  as  the  shoulders 
and  also  lead  to  limited  motion  in  the  upper  thigh. 

The  patient  must  retain  his  urine  until  the  bowels  have  moved,  as 
otherwise  the  stool  is  discharged  simultaneously  with  the  urine. 

The  bowel  evacuations  are  copious,  muco-sanguineous.  As  fre- 
quently is  the  case,  so  also  here,  we  have  a  patient  attacked  by  cancer,  who 

1.  comes   from  lo«ig  lived  parents; 

2.  has  had   no   infectious  diseases ;   and 

3.  was  always  healthy. 


CARCINOMA    OF    THE    LARGE    INTESTINE  291 

Case  13. — J.  U.,  34  years,  M.    Day  laborer. 

ad  1. — Mother  is  living  cind  well. 

ad  3. — As   a  child  had  measles ;  at  9  years  of  age  had  pleurisy. 

ad  6. — In  the  spring  of  1904,  after  eating  fat  meat,  there  occurred 
diarrhea,  which  lasted  four  "days.  During  the  summer  of  1904<  no  com- 
plaints. In  November,  1905,  renewed  diarrhea,  at  first  two  to  three  times, 
later  four  to  seven  times  a  day.  In  January,  1906,  twelve  to  fifteen  evac- 
uations per  day ;  in  the  beginning  they  were  painless.  Appetite  very  good, 
food  is  without  influence  on  the  number  of  evacuations.  Later  there  were 
eight  day  intervals  between  stools,  after  which  there  occurred  very  co- 
pious bowel  movements  accompanied  by  severe  pain;  in  addition  to  this, 
feculent  eructation.  Since  January  of  this  year  (1906)  often  twelve  to 
sixteen  movements  a  day,  consisting  mostly  of  a  little  bloody  mucus ; 
tenesmus.  After  ingestion  of  food  often  immediate  distention  in  the 
epigastrium ;  no  vomiting.  For  the  past  three  months  offensive  odor  in 
the  mouth,  "as  if  he  had  washed  the  mouth  with  urine."  During  two  y^ars 
the  patient  has  lost  only  4  kg  in  weight.    No  pain  in  the  back. 

ad  7. — Yellowish  pale  color  of  the  face.  Splashing  sounds  in  the 
epigastrium.  Hard  scybala  in  the  sigmoid  flexure.  Mildly  febrile  course 
with  temperature  elevations  between  37°   C.  and  38°   C. 

Bowel   evacuations:   Muco-sanguineous   masses,   containing   abundant 
spirochetes. 

Rectoscopic   examinations:  Nine  cm  above   the   sphincter  there   is   a 
hard  tumor-mass  on  the  anterior  wall. 

Histological  examinations:  Adenocarcinoma. 

ad  8.- — Beginning:   Spring,  1904   (?). 

Status  presens:  March  20,  1906. 

ad  9. — Diagnosis :  Ulcerating  carcinoma  of  the  rectum. 
Epicrisis:  The  diarrhea  occurring  in  the  spring  of  1904,  apparently 
caused  by  a  dietetic  error,  and  repeated  later  on,  even  though  after  long 
free  intervals,  may  have  been  due  to  the  cancerous  disease.  During  the 
subsequent  course  of  the  disease  there  were  often  long  periods  during 
which  no  bowel  movements  occurred,  accompanied  by  feculent  eructation, 
and  ending  with  very  massive  evacuations  attended  by  very  severe  pain. 
The  appetite  remains  good  for  a  long  time,  which  would  account  for 
the  slight  loss  in  weight  (4  kg  in  two  years).  The  patient  was  only  34 
years  of  age. 

Case  14.— Th.  R.,  64  years,  M. 

ad  5.- — Never  was  sick. 

ad  6. — In  the  autumn  of  1906  there  began  diffuse  abdominal  pains 
and  diarrhea.  Stools  very  often  discolored  wnth  blood ;  since  November, 
1906,  there  is  vomiting  after  almost  every  intake  of  food. 

ad  7.* — Pale  yellow  face  color.  Inferior  abdominal  region  slightly 
sensitive  to  pressure  on  both  sides.  Soft  edema,  extending  over  the 
thigh  and  belly-wall,  including  the  sacrum.  After  a  test-breakfast  of  tea 
and  a  roll  there  is  no  HCl. 


292  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Stool  evacuations:  Mucus,  pus,  blood. 

Rectoscopic  examination:  At  the  height  of  14-15  cm  there  begins  a 
bleeding  neoplasm,  having  a  hard  border,  circular,  completely  ul- 
cerating. 

ad  8. — Beginning:  Autumn,  1906. 

Status  presens:  March  30,  1907. 
ad  9. — Diagnosis :  See  rectoscopic  finding. 
Epiciisis:  Gastric  symptoms  appear  prominently  in  this  case;  vomit- 
ing after  every  intake  of  nutrition,  absence  of  HCl.      Yet  the  character 
of  the  stools  (bloody,  purulent  masses  of  mucus)  speaks  for  deep  situa- 
tion of  the  disease. 


Primary  Carcinoma  of  the  Liver 

Case  1. — F.  J.,  64  years,  M.    Metal  grinder. 

ad  4. — Never  had  any  ga.stro-intestinal  disturbances. 

ad  5. — Never  was  seriously  sick.  In  July,  1904),  had  pain  an- 
teriorly over  the  chest  together  with  dyspnea,  occurring  especially  when 
walking   rapidly. 

ad  6. — In  the  beginning  of  November  he  accidentally  noticed  a 
hard  resistance  above  the  umbilicus,  not  painful  on  pressure.  The 
appetite  remained  good,  stool  somewhat  retarded.  Particularly  in  the 
evening  hours  there  was  a  feeling  of  distention  and  fulness  in  the  ab- 
domen. No  eructation,  no  vomiting,  no  colics.  Rapid  growth  of  the 
epigastric  tumor-mass ;  during  the  past  six  weeks  has  lost  10  kg  in 
weight.  Of  late,  frequent  bleedings  from  the  gums.  Perfectly  pain- 
less course. 

ad  7. — No  icterus ;  no  ascites.     Liver  greatly  enlarged,  extraor- 
dinarily  hard,   not   painful   on   pressure ;   dilatation    of   veins.      Systolic 
murmur   over   the   liver.      Spleen   just    about   palpable,    hard.     Afebrile 
course.     Double  murmur  over  the  aorta,  pulse  rapid. 
Urine:  Urobilin   positive;   no  diazo   reaction. 

Blood:  4,900,000  erythrocytes,  14,500  leucocytes,  60%  hemoglobin. 
Slight  polychromasis,  few  normoblasts. 

November  30,  1904:  At  9  p.m.  sudden  loud  screaming,  jerkings  in 
the  right  half  of  the  face,  loss  of  consciousness.  After  half  an  hour 
the  patient   regains  partial  consciousness,   renewed  attack;  death. 

ad  8. — Beginning:  Early  part  of  November,  1904. 
Status  presens :  November  28,  1904. 
Autopsy:  December  1,  1904. 

ad  9. — Autopsy  (Hofrat  Professor  Dr.  A.  Weichselhaum)  :  In- 
tense diffuse  atheroma  of  ascending  and  descending  aorta  with  great 
dilatation  of  same.  Insufficiency  of  the  aortic  valves.  Left-sided 
hemorrhage  of  the  cerebrum.  Carcinomatous  cirrhosis  of  the  liver  with 
metastases  in  the  retroperitoneal  and  bronchial  lymph-nodes  as  well 
as  in  the  visceral  layer  of  the  peritoneum.      Slight  hydrops,  ascites. 

Epicrisis:  The  unusually  intense  atheroma  of  the  thoracic  and  ab- 
dominal aorta  might  lead  one  to  think  of  an  underlying  dyscrasia. 
The  differential  diagnosis  was  really  limited  to  a  cirrhosis  of  Laennec 
(first  stage).  This  could  be  ruled  out  by  the  rapid  increase  in  the  size 
of  the  liver  as  stated  in  the  patient's  history.  Neither  was  there  a 
leucopenia  so  frequently  met  with  in  cirrhoscs  of  Laennec,  but  rather 
a  moderate  leucocytosis   (14,500). 

The  process  ran  a  painless  course,  without  icterus,  without  jaundice. 

293 


294  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  2.— W.  F.,  62  years,  M. 

ad  3. — 111  1867  had  typhoid  for  seven  weeks ;  in  1904<  erysipelas 
of  the  face. 

ad  4. — Since  childhood  had  a  tendency  to  "colds"  and  diarrhea, 
ad  5. — Was    always    healthy    and    strong.     In    1879    a    rapidly 
transient  attack  of  hemiplegia  (left  side). 

ad  6. — Since  about  June,  1904,  on  and  off  mild  twingeing  in  the 
region  of  the  liver.  In  August,  1904,  while  working  in  a  stooping 
position  sudden  extremely  violent  pain  underneath  the  right  costal  arch, 
had  to  sit  down  immediately.  The  pain  continued  with  great  intensity 
for  one  hour  and  since  then  has  never  ceased  entirely.  It  is  present 
especially  when  coughing  and  when  lying  on  the  left  side,  now  and  then 
radiating  backward  into  the  region  of  the  kidney.  No  vomiting,  no 
chill.  Even  now  the  appetite  is  very  good  (October,  1904).  Bowels 
are  regular.  Since  about  July,  1904,  has  emaciated  from  92  to  66  kg. 
Weakness  and  fatigue. 

ad  7. — October  8,  1904:  No  icterus,  no  ascites.  Cachectic  color 
of  the  face  with  capillary  dilatations  on  the  checks.  Tenderness  to 
pressure  underneath  the  right  costal  arch.  Liver  much  enlarged,  pro- 
jecting from  underneath  the  right  costal  arch,  very  hard.  Over  the 
riglit  lobe  there  is  a  blowing  systolic  murmur.  Corresponding  to  the 
hepatic  flexure  of  the  colon  there  is  bowel  gurgling  luiving  a  metallic 
sound.  The  spleen  extends  to  the  costal  arch,  and  is  firm.  No  venous 
dilatations  over  the  epigastrium.  Systolic  murmur  over  the  heart  and  in 
the  carotids;  moderate  lime  deposits  in  the  radial  artery.  No  edemas; 
temperature   mostly  36°    C. 

Urine:   No   urobilin,    no    aliimntary    glycosuria. 
Blood:  10,800  leucocytes. 

January  2,  1905 :  Severe  fvscites,  venous  dilatation  in  the  epigas- 
trium. Systolic  murmur  over  the  right  hepatic  lobe  has  disappeared. 
Severe,  soft  edema  in  tlie  lower  extremities  and  at  the  sacrum.  Afebrile 
course,  36°   C. 

Urine:  Abundance  of  urobilin;  no  diazo  reaction. 

Stomach:  Total  acidity,  after  test-breakfast,  9%,  ho  N.  Na  OH. 
HCl  negative. 

Feces:  Alternately  ribbon-shaped  and  well  formed;  bowel  movements 
regular. 

ad  8. — Beginning:  June,  1904. 

Status   presens :   October   8,    1904,   and   January   2,    1905. 
Autops}':  January  16,  1905. 
Duration:  About  6  months, 
ad  9. — Autopsy  (Docent  Dr.  J.  Bartel)  :  Carcinoma  of  the  right 
hepatic  lobe  with  metastases  in  the  liver,  periportal  lymph-nodes  and  in 
the   lungs.     Ascites    clndosus.     Healed   endocarditis    of   the    aortic   valve 
with  insufficiency  of  same.    Atheroma  of  the  arch  of  the  aorta  and  severe 
atheroma  of  the  peripheral   arteries   with  much   calcification. 

Epicrisis:  The  cancer  proliferation  in  this  case  affected  chiefly  the 
right   hepatic   lobe,   leading  to   much   thickening   and   other   chronic    in- 


PRIMARY    CARCINOMA    OF    THE    LIVER  295 

ri;uiiiiuit()ry  altcrjitions  of  the  pcritoncjil  covi-riiio-  of  the  liver.  To  this 
local  peritonitic  process  may  be  referred  tlie  pain  which  ushered  in  tlie 
disease    and    accompanied    it    practically    throughout    tlie    entire    course. 

This  exquisitely  painful  course  of  the  disease  constituted  in  itself 
a  distinguishing  mark  against  the  assumption  of  a  cirrhotic  process. 
The  latter  was  also  ruled  out  by  the  auscultatory  finding  of  a  blowing, 
strictly  systolic  murmur  over  the  right  hepatic  lobe,  wiiich  subsequently 
disappeared  (murmur  due  to  arterial  compression!).  The  absence  of 
urobilinogenuria  is,  according  to  my  personal  experience,  found  much 
more  seldom  in  cirrhotic  diseases  of  the  liver  than  in  localized  malignant 
processes.  The  rapid  increase  of  urobilinogenuria  from  zero  to  a  con- 
siderable amount  (January,  1905)  may  have  some  connection  with  the 
acuteness  of  the  underlying  process. 

"Milky"  ascites  is  found  far  more  frequently  with  malignant  diseases 
of  the  abdomen  than  with  benign  conditions.  In  this  case  we  were  very 
likely  dealing  with  congestion  of  chyle  due  to  glandular  metastases 
(around  the  pancreas).  The  coincidence  of  a  large  liver  and  large  ab- 
domen (as  a  result  of  ascites)  could  also  be  interpreted  as  a  malignant 
syndrome. 

The  perfectly  afebrile  course  did  not  well  accord  with  the  assump- 
tion of  a  tumor  formation  springing  from  the  biliary  passages. 

The  intestinal  flora  was  throughout  Gram-negative.  Such  behavior 
is  unusual  with  gastric  or  intestinal  neoplasms.  Gastric  cancers  at 
least  in  a  large  percentage  of  cases  in  the  later  stages  lead  to  the  ap- 
pearance of  Gram-positive  lactic-acid  bacilli  in  the  stools ;  intestinal 
neoplasms   are   frequently   accompanied  by  Gram-positive   cocci. 

The  radial  vessels  were  found  to  be  much  sclerosed. 

Case  3. — J.  B.,  55  years,  M.    Tailor's  assistant. 

ad  1. — Mother  succumbed  to  a  pulmonary  disease  at  68;  like- 
wise a  brother  at  33. 

ad  3. — Has  had  no  infectious  diseases. 

ad  5. — Admits   moderate  use   of  alcohol. 

ad  6. — In  October,  1904,  the  former  excellent  appetite  became 
diminished,  there  set  in  a  particular  disinclination  toward  meat,  the  use 
of  which  was  followed  by  pressure  in  the  stomach.  Stool  became  re- 
tarded, now  and  then  being  very  light  in  color.  The  patient  became 
pale,  emaciated  to  the  extent  of  10  kg.    Afebrile  course. 

March,  1905:  Swelling  of  the  legs.  Facial  color  pale,  no  icterus, 
moderate   ascites. 

ad  7. — Liver  moderately  enlarged,  firm,  not  painful;  no  vascular 
murmurs.  Soft,  pale  edema  of  the  legs;  edema  at  the  sacrum.  Afebrile 
course. 

Stomach  contents:  Total  acidity  after  test-breakfast,  80'/r,  HCl 
40%.  Pepsin  and  eff'ect  of  rennet  normal.  Toward  the  end  "coffee- 
ground"  vomiting,  few  sarcina^. 

Urine:  One-quarter  per  cent,  sugar.  Strong  aldehyde  reaction. 
Toward  the  end  both  findings  negative  (thrombosis  of  the  portal  vein). 


296  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Blood:  Eighty  per  cent,  hemoglobin,  7,900  leucocytes. 
'  Ascitic  fluid:  sp.  gr.  1015,  "milky,"  cytological  finding  negative, 
ad  8. — Beginning:  October,  1904. 

Status  presens:  March  16,  1905.  • 

Autopsy:  April  1,  1905. 
Duration :  6  months, 
ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Primary  carcinoma 
of  the  liver  (weight  2450  g)  in  an  atrophic  cirrhosis  with  green  dis- 
coloration of  the  tumor-masses ;  thrombosis  of  the  branches  of  the  por- 
tal vein  after  the  tumor  had  perforated  into  same.  Ascites,  splenic 
tumor,  venous  dilatations  in  the  stomach  and  the  lower  end  of  the 
esophagus.  "Coffee-ground"  contents  in  the  stomach  and  bowel.  In- 
durations in  the  right  pulmonary  apex. 

Epicrisis:  Similarly  as  in  Case  2,  the  right  hepatic  lobe  was  affected 
also  in  this  case.  The  rapid  course  (6  months)  and  the  early  appear- 
ance of  cachectic  general  symptoms  (emaciation,  facial  pallor,  weak- 
ness, edema)  spoke  against  a  cirrhosis  of  Laennec.  Meat  anorexia  be- 
longed to  the  early  symptoms,  although  the  chemical  findings  of  the 
stomach  proved  normal.  This  case  illustrates,  among  other  things,  the 
diagnostic  rule  that  preagonal  gastric  findings,  as  in  this  case  "coffee- 
ground"  vomiting  and  the  presence  of  a  few  sarcina?,  are  to  be  adjudged 
lightly. 

The  urobilinogenuria,  existing  originally  (strong  aldehyde  reac- 
tion), and  glycosuria,  disappeared  during  the  terminal  stage,  possibly 
under  the  influence  of  the  developing  thrombosis  in  the  portal  vein. 

Case  4. — S.  E.,  63  years,  F.    Seamstress. 

ad  3. — Has  had  no  infectious  diseases, 
ad  4. — Never  had  any  gastric   complaints. 

ad  6. — In  October,  1908,  there  began  pain  in  the  region  of  the 
stomach  and  sour  eructation.  Almost  at  the  same  time  the  abdomen  be- 
came enlarged.    No  vomiting. 

ad  7. — No   icterus ;   ascites,   edema   of   the   legs.     Numerous    small 
tumor-masses  (like  glands)  can  be  felt  in  the  right  half  of  the  abdomen. 
Urine:  Suggestion  of  an  aldehyde  reaction;  diazo  reaction  negative. 
Feces:  Test  for  blood-coloring  matter  is  negative, 
ad  8. — Beginning:  October,   1908. 

Status  presens :  November  23,  1908. 
Autopsy:   November  29,   1908. 
Duration :  2  months, 
ad  9. — Autopsy    (Pros.   Professor  Dr.  Fr.  Schlagenhaufer). 
Epicrisis:    Tumor-masses    in    a    "corset    lobe"    are    easily    misinter- 
preted ;  the  "corset"  groove  may   pass   as  the  border  of  the  liver  and 
owing  to  the  slight   resistance  which  a  "corset  lobe"  offers  to  the  pal- 
pating hand  one  easily  gains  the  impression  of  greater  relative  mobility 
of  the  tumor-masses. 

The  constantly   negative  finding   in   the   feces,   in   testing   for   blood- 


PRIMARY    CARCIxNOMA    OF    THE    LIVER  297 

coloring  matter,  rendered  an  ulcerative  process  in  the  gastro-intestinal 
tract  higlily  improbable. 

The  rapid  course  of  the  disease  in  particular  spoke  against  a  cir- 
rhosis of  Laennec,  syphilis,  etc. 

Without  doubt  precisely  primary  cancers  of  the  liver  may  for  a 
long  time  remain  latent  as  far  as  the  subjective  symptoms  in  the  patient 
are  concerned,  which  may  also  in  part  explain  the  usually  acute  clinical 
course  of  the  disease. 

Case  5. — A.  Sch.,  65  years,  M.    Lacemaker. 

ad  3. — \'aricella  at  9  years  of  age ;  otherwise  no  infectious 
diseases. 

ad  4. — During  childhood  often  had  colicky  pain  in  the  belly  at 
intervals  of  18  to  24  days;  bowels  always  regular.  Never  any  icteinis. 
Appetite  always  very  good.  Constant  tendency  to  flatulence.  For  the 
past  twenty  years  the  stools  are  said  never  to  have  been  dark-brown 
but  always  of  a  light  yellow  color,  otherwise  mostly  regular  and  well 
formed.    Even  very  solid  stools  were  usually  colored  light  yellow. 

ad  5. — Fifteen  years  ago  the  thyroid  gland  began  to  enlarge. 

ad  6. — Bad  appearance  for  the  past  tAvo  years.  In  May,  1901, 
the  abdomen  enlarged,  and  there  appeared  edema  in  the  legs  and  scro- 
tum. Dyspnea.  These  complaints  again  retrogressed.  In  July,  1901, 
the  patient  noticed  that  the  region  on  the  right  side  underneath  the  cos- 
tal arch  bulged  somewhat  and  was  tender  on  pressure.  Appetite  good. 
Bowels  regular.  Toward  the  end  of  January,  1903,  he  noticed  in  the 
mouth,  at  a  place  corresponding  to  the  ramus  of  the  lower  jaw,  a  pain- 
less swelling,  which  grew  to  the  size  of  a  walnut  and  during  the  past 
few  days  (April,  1903)  began  to  bleed.  On  coughing  there  is  a  stabbing 
pain  in  the  back  and  in  the  region  of  the  liver;  on  standing  erect  there 
is  a  sensation  that  something  in  the  right  side  of  the  abdomen  is  pulling 
downward.  Since  the  middle  of  March  of  this  year  (1903)  there  is 
swelling  of  the  legs. 

ad  7. — No  icterus ;  no  particular  cachexia.  Underneath  the  right 
costal  arch  in  the  region  of  the  liver  there  is  a  greatly  projecting 
tumor  formation,  about  the  size  of  an  apple,  having  a  tensely  elastic 
consistence.  Liver  slightly  enlarged  in  toto,  only  little  tender  on  pres- 
sure. Spleen  is  palpable,  extending  to  the  costal  arch,  ^'enous  dilata- 
tions over  the  lower  part  of  the  sacrum.  In  the  oral  cavity,  on  the 
ramus  of  the  low^er  jaw,  there  is  a  tumor  the  size  of  a  walnut,  discolored 
dark  red,  soft,  apparently  fluctuating,  bulging  also  externally.  Soft, 
retromalleolar  edema. 

ad  8. — Beginning:  May,   1901. 

Status  presens:  April  21,  1903. 
Autopsy:  May  16,  1903. 
Duration :  About  2  years. 

ad  9. — Autopsy  (Professor  Dr.  0.  Stoerk)  :  Adenocarcinoma  of 
the  right  hepatic  lobe  with  metastases  in  the  lungs  and  the  left  ranuis  of 


298  TUMORS    OF    THE    ABDOMINAL    VISCERA 

the  lower  jaw.  General  arteriosclerosis,  struma  cystica  of  the  right 
lobe  of  the  thyroid  gland.     Arteriosclerotic  contracted  kidney. 

Epicrisis:  As  in  Cases  2  and  3,  so  also  here  it  was  chiefly  the  right 
hepatic  lobe  that  was  the  seat  of  the  cancer  proliferation.  One  might 
be  tempted  to  connect  the  abnormally  light  color  of  the  stools  twenty 
years  ago  with  a  disturbance  in  the  biliary  secretion  and  attribute  it  to 
a  pre-existent  adenomatous  formation  of  the  liver. 

Exceptionally  the  hepatic  tumor-mass  was  not  tough-  but  of  a  tensely 
elastic  consistence. 

The  metastasis  situated  in  the  ramus  of  the  lower  jaw  showed  exactly 
the  same  consistence. 

Case  6. — H.  B.,  18  years,  M.    Machinist  apprentice. ^^ 

ad  1. — Father  is  living  and  is  well ;  mother  was  treated  at  the  clinic 
in  1897  for  cancer  of  the  stomach. 

ad  2. — Since  childhood  has  been  inclined  to  headaches,  radiating 
from  the  occiput  to  the  front. 

ad  3. — Has  had  none  of  the  diseases  of  childhood. 

ad  5. — Was  always  healthy;  in  childhood  had  a  tendency  to  ca- 
tarrh of  the  respiratory  passages  during  the  cold  seasons  of  the  year. 

ad  6. — About  January  1,  1899,  feeling  of  pressure  in  the  epi- 
gastrium after  eating  soup.  Vomiting.  Subsequently  pain  anteriorly 
on  a  level  with  the  umbilicus,  girdle  shaped,  with  tenderness  on  pressure 
in  both  hypochondriac  regions ;  increase  of  the  complaints  on  motion 
and  when   lying  on   the   side.    Anorexia ;  bowels   regular. 

ad  7. — Frail  individual.  No  hairs  in  the  axilla,  infantile  testicles. 
Rachitic  cranium.  Sub-icteric  discoloration.  Liver  moderately  en- 
larged, firm,  with  a  protuberance  in  the  epigastrium  about  the  size  of  a 
walnut,  very  sensitive  to  pressure.  Blowing  systolic  murmur,  especially 
on  the  right  side  underneath  the  costal  arch,  also  demonstrable  in  the 
right  middle  axillary  line.  Venous  dilatations  over  the  abdomen.  Spleen 
palpable,  hard.    No  ascites,  no  edema. 

Urine:  Abundance  of  urobilin;  bilirubin  negative. 
Blood:  5,100,000  erythrocytes,  9,300  leucocytes,  80%  hemoglobin. 
During  the   further  course  there  were   continued   pain,   occasionally 
radiating   toward   the   right    shoulder ;   appearance   of   ascites ;    frequent 
vomiting;    diarrhea.     Only    toward    the    end   there   was    bilirubin    in    the 
urine.     Temperature  ranged  between  36°  C.  and  37.3°  C. 

ad  8. — Beginning:  Early  part  of  January,  1899. 
Status  presens:  January  15,  1899. 
Autopsy:  January  28,  1899. 

ad  9. — Autopsy  (Professor  Dr.  H.  Albrecht)  :  Adenocarcinoma 
of  the  liver,  with  enormous  intumescence  of  the  liver  and  spleen  in  an 
old  pylephlebitic  cirrhosis ;  thrombosis  of  the  portal  vein.  Metastases 
in  the  lungs.    Icterus.    Fresh  fibrinous  purulent  peritonitis. 

"^  See  E.  Lindner.  Wiener  Klin.  "Wochenschr.,  1899,  No.  44. 


PRIMARY    CARCINOMA    OF    THE    1,1  VKK  299 

Ejncrisis:  Primary  cancer  of  the  liver  in  an  18-year-ol(l  individual 
with  numerous  indications  of  a  hypoplastic  constitution  (absence  of 
hairs  in  the  axilla,  infantile  testicles,  meduUated  nerve-fibres  at  the  pa- 
pilla, multiple  small   f^landular  swellings). 

The  disease  began  suddenly',  accompanied  by  gastric  symptoms  and 
hepatalgias  (radiation  toward  the  right  shoulder!);  during  the  further 
course  there  occurred  diarrheas  (thrombosis  of  the  portal  vein).  Only 
toward  the  end  did  bilirubin  appear  in  the  urine;  at  the  start  there  was 
great  urobilinuria.  According  to  the  opinion  of  the  anatomist  the 
adenocarcinoma  was  superimposed  on  a  pylephlebitic  cirrhosis;  clini- 
cally this  disease  had  inin  a  symptomless  course  and  only  the  large 
splenic  tumor  could  remind  one  of  a  pre-existent  cirrhotic  disease.  The 
anatomical  beginning  of  the  cancer  was  probably  at  an  earlier  date  than 
the  appearance  of  the  clinical  symptoms  (hardly  a  month  prior  to 
death)   would  permit  one  to  assmne. 

Case  7.— S.  P.,  29  years,  M. 

ad   1. — Parents  are  living  and  well. 

ad  3.— Aside  from  disease  lasting  5  days,  to  be  mentioned  later, 
has  had   no   febrile  condition. 

ad  4. — At  22  years  of  age  suffered  from  some  stomach  trouble 
for  about  three  weeks,  which  was  accompanied  by  pressure  in  the  stomach 
and  vomiting. 

ad  5. — Was  othei-Avise  healthy  until  September,  1905.  At  that 
time  while  in  Dischibuti  (French  coast  of  Somali  in  Africa)  was  taken 
with  ja^llow  fever  (up  to  -il"  C.)  ;  this  disappeared  in  five  days  under 
quinine  therapy. 

ad  6. — In  April,  1906,  pain  in  the  epigastrium,  when  sitting  up 
or  turning  from  the  left  side  to  the  right.  Cold  compresses  had  a  favor- 
able effect.    Digestion  normal  at  the  start. 

Middle  of  May,  1906:  Sudden  stabbing  and  burning  pain  above  the 
umbilicus  and  on  both  sides  of  the  back.  Pressure  on  the  epigastrium 
causes  pain  in  the  right  shoulder.  Pain  in  the  right  scapula.  The  pain 
is  least  when  the  patient  is  lying  on  the  back  with  knees  drawn  up. 
Middle  of  June,  1906:  Attacks  of  fever  for  five  days. 
June  19-26,  1906:  Pain  especially  on  the  right  side  below  the  costal 
arch,  also  to  the  left  of  the  umbilicus.  No  icterus,  color  of  the  urine 
strikingly  dark  since  the  beginning  of  May  of  this  year  (1906). 
Night-sweats. 

In  the  middle  of  May,  1906,  a  tumor-mass  was  for  the  first  time 
found  to  the  left  of  the  umbilicus.  According  to  the  statement  of  the 
patient,  the  physician  in  attendance  suspected  echinococcus  or  liver 
abscess. 

ad  7. — No  cachectic  appearance,  no  edemas,  no  ascites,  no 
icterus.  Both  lobes  of  the  liver  equally  much  enlarged,  very  firm,  sur- 
face smooth,  not  sensitive  to  pressure.  No  vascular  nuirmurs,  no  venous 
dilatations.    Spleen  not  enlarged. 


300  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Urine:  On  exposure  to  the  air  became  pronouncedly  black!  This 
black  discoloration  could  also  be  produced  by  adding  drops  of  fuming 
HNOa,'  by  a  solution  of  ferric  chloride  and  tincture  of  iodine.  In  per- 
forming Legal'.s  acetone  test  on  addition  of  sodium  nitro-prusside  and 
KOH  the  urine  took  on  a  purple-violet  color,  on  the  addition  of  glacial 
acetic  it  turned  blue !  Aldehyde  reaction  positive.  Diazo  reaction 
present  in  traces. 

Blood:  4,064,000  erythrocytes,  15,400  leucocytes,  hemoglobin  80%, 
namely : 

Polynuclears,   76%. 
Lymphocytes,    12%. 
•    Large  monon,  11%. 
Mast  cells,  0.1%. 
Eosinophiles, — 
Toward  the  end  bloody  stools  and  bloody  vomiting. 

ad  8. — Beginning:   April,    1906    (September,    1905.''). 
Status  presens :  July  5,  1906. 
Autopsy:  August  12,  1906. 
Duration:  4  months, 
ad  9. — Autopsy    (Professor    Dr.    A.    Glion)  :    Melanosarcoma    of 
the  liver,   with  enormous   hypertrophy   of   same   and   thrombosis    in   the 
ramifications  of  the  portal  vein.    Melanosarcoma  of  the  lymph-nodes  at 
the  porta   of  the  liver   and   in   the   retroperitoneal  lymph-nodes.     Slight 
icterus.    The  liver  weighs  8  kg,  50  dkg.    Surface  smooth. 

Epicrisis:  This  is  a  case  of  melanosarcoma  of  the  liver  with  typical 
urinary  findings,  which  comes  under  the  discussion  of  primary  cancer 
of  the  liver  inasmuch  as  there  is  no  demonstrable  point  of  origin  out- 
side of  the  liver  (chorioidea,  najvus,  etc.). 

At  the  time  of  his  entrance  the  patient  brought  with  him  a  urinary 
report  bearing  the  remark :  tannic  acid  positive. 

This  peculiar  finding — the  patient  denied  ever  having  taken  medica- 
ments containing  tannic  acid — together  with  the  enormous  intumescence 
of  the  liver  immediately  aroused  the  suspicion  of  a  melanosarcoma,  which 
was  confirmed  even  by  a  hasty  examination  of  the  urine. 

The  addition  of  ferric  chloride  actually  caused  a  black  discoloration 
of  the  urine,  and  this  had  led  to  the  assumption  of  tannic  acid  in  the 
urine. 

But  other  oxidizing  influences  had  the  same  effect,  thus  exposure  of 
the  urine  to  the  air,  addition  of  a  few  drops  of  fuming  nitric  acid  or  of 
tincture  of  iron.  Legal's  test  for  acetone  yielded  a  blue  color  on  the 
addition  of  glacial  acetic. 

Hence  we  were  dealing  not  with  tannic  acid  but  with  melanin. 
It  was  surprising  that  despite  the  enormous  enlargement  of  the  liver 
(8  kg)  there  was  no  real  cancerous  cachexia  and  no  edemas.    This  may 
have  contributed  to  the  fact  that — as  stated  by  the  patient — an  echino- 
coccus  infection  or  liver  abscess  had  been  thought  of. 

The  latter  assumption  may  have  been  strengthened  by  the  patient's 
previous    sojourn   in    the   tropics    and   the    occasional    attacks    of   fever. 


PRIMARY    CARCINOMA    OF    THE    LIVER  301 

The  autopsy  did  not  disclose  any  complications  which  would  account 
for  the  febrile  movements  and  very  likely  they  were  dependent  on  the 
malignant  process  which  had  perhaps  set  in  even  in  September,  1905 
(first  febrile  attack).  The  process  was  ushered  in  by  perihepatic  pain 
and  the  fact  that  pressure  in  the  epigastrium  elicited  pain  in  the  right 
shoulder,  desel'^'es  attention. 

As  in  most  cases  of  primary  and  secondary  neoplasms  of  the  liver,^^ 
so  also  here,  there  appeared  a  distinct  icterus. 

The  patient  was  29  years   of  age. 

"  Exclusive  of  the  forms  originating  in  the  gall-bladder  and  biliary  passages. 


Secondary  Carcinoma  of  the  Liver 


30 


Case  1.— N.  N.,  42  years,  M. 

ad  3. — Had  smallpox  and  diphtheria. 

ad  6. — In  March,  1905,  there  began  a  feeling  of  pressure  in  the 
epigastrium  which  became  increased  after  ingestion  of  food;  at  the  start 
it  would  often  be  absent  for  one  week.  Duration  mostly  one-quarter  of 
an  hour.  Constant  increase  of  the  symptom  during  the  course  of  the 
disease. 

In  the  middle  of  December,  1905,  the  epigastrium  began  to  bulge; 
the  bulging  increased  rapidly  during  the  past  three  weeks.  The  urine 
became  darker,  the  stools  light. 

Since  the  end  of  December,  1905,  the  patient  can  lie  only  on  his 
right  side  with  legs  drawn  up ;  every  change  in  position  is  exceedingly 
painful.  On  and  off  increasing  and  decreasing  feeling  of  pressure  in 
the  epigastrium,  at  the  same  time  pain  in  the  back.  Anorexia,  consti- 
pation. 

ad  7. — Facial  color  pale,  no  icteinis,  no  ascites.  The  patient  con- 
stantly occupies  the  right  lateral  position.  The  liver  is  enlarged,  very 
firm ;  a  systolic  murmur  can  be  heard  in  the  area  of  the  right  lobe ; 
venous  dilatations  across  the  right  costal  arch.  Spleen  is  not  enlarged. 
No  edemas. 

January  6,  1906:  Temperature  elevations  up  to  39.4°  C. ;  herpes 
labialis. 

Urine:  Strongly  positive  aldehyde  reaction. 

Blood:  5,136,000  erythrocytes^  11,000  leucocytes,  hemoglobin  77%. 
ad  8. — Beginning    (stomach)  :    March,    1905    (liver)  :    middle    of 
December,  1905. 

Status  presens:  January  5,  1906. 
Autopsy:  January  22,  1906. 
ad  9. — Autopsy     (Professor     Dr.     A.     Glion)  :    Medullar}',     non- 
stenosing   carcinoma    of   the    stomach;    diffuse    metastases    in    the   liver, 
partly    nodular,   partly    diffusely    infiltrating,    with    enlargement    of   the 
liver.    General  icterus.    Perihepatitis  and  perisplenitis. 

EpicHsis:  This  case  shows  that  metastases  in  the  liver,  which  fre- 
quently may  run  an  almost  painless  course,  though  the  liver  be  enor- 
mously enlarged,  may  exceptionally  be  accompanied  by  unusually  severe 

'"  I  confine  myself  to  the  presentation  of  one  atypical  case,  in  which  the  phenomena 
of  pain  and  febrile  manifestations  stand  clinically  in  the  foreground. 

302 


SECONDARY    CARCINOMA    OF    THE    LIVER  303 

pain,  nanicl}'  in  those  cases  where  a  diffuse  acute  perihepatitis  super- 
venes. 

According  to  my  observation  the  niedulhiry,  severely  ulcerating  can- 
cers of  the  gastro-intestinal  tract  are  the  ones  which  with  synchronous 
metastasis  in  the  liver  most  frequently  occasion  severe  perihepatitis. 
Very  likely  we  are  here  dealing  with  a  simultaneous  invasion  of  inflam- 
mator}'  excitants  from  the  ulcerating  surface.  On  account  of  the  severe 
perihepatitis,  which  was  accompanied  b}^  high  rises  in  temperature  and 
herpes  labialis,  the  patient  was  inunobilized  in  the  right  lateral  position. 

There  are  cases  in  which  one  could  easily  erroneously  suspect  inflam- 
matory infectious  diseases  of  the  liver  (cholangitis,  abscess  of  the  liver, 
cholelithiasis,  syphilis,  etc.). 


Carcinoma  of  the  Gall-Bladder,  Including  the 
Biliary  Passages  and  the  Papilla  of  Vater'' 


Case  1.— N.  N.,  60  years,  F. 

ad  6. — Beginning  of  the  symptoms  at  Christmas,  1897,  with 
icterus,  which  at  the  start  was  of  varying  intensity.  No  pain.  For  sev- 
eral months  there  has  been  moderate  vomiting,  of  late  vomiting  of 
"coffee-ground"  masses. 

ad  7. — Ictcinis.     Hard,    almost    angular   tumor    corresponding   to 
the  gall-bladder;  surrounding  it  are  button-like  hard  nodules.    Dilata- 
tion  of  the   stomach.     The   gastric   contents   contain   abundant  sai'cinae, 
only  a  few  isolated  lactic-acid  bacilli ;  of  late  there  is  diarrhea, 
ad  8. — Beginning:  Christmas,   1897. 

Status  presens:  End  of  August,  1898. 
Autopsy:  End  of  August,  1898. 
Duration:  About  8  months, 
ad  9. — Autopsy:   Carcinoma   of   the   gall-bladder    (cholelithiasis). 
Epicrisis:  The  carcinoma  of  the  gall-bladder  had  led  to  a  stenosis 
of  the  pylorus  and  thus  to  the  occurrence  of  sarcins  in  the  stomach  con- 
tents ;  at  the  end,  as  a  result  of  parenchymatous  hemorrhages  from  the 
gastric  mucosa,  there  occurred  also  "coffee-ground"  vomiting. 

When  with  a  general  cachexia,  there  is  a  coexistence  of  icterus  and 
sarcinae  we  should  think  not  only  of  cancer  of  the  pancreas  but  also  of 
cancer  of  the  gall-bladder. 

An  angular  form  and  especial  hardness  is  peculiar  to  gall-bladders 
that  are  contracted  and  filled  with  calculi. 

Case  2. — 0.  Th.,  67  years,  F.     Housekeeper. 

ad  2. — At  60  years  of  ago  had  a  severe  acute  articular  rheuma- 
tism affecting  all  the  joints  and  lasting  three  months, 
ad  5. — Was  always  healthy. 

ad  6. — In  September,  1899,  the  patient  lost  her  appetite,  was 
nauseated  by  meat.    Constipation  set  in. 

About  October,  1899,  her  attention  was  called  to  the  yellow  color 
of  her  skin.    Appetite  again  improved. 

In  November,  1899,  there  appeared  pain  in  the  back,  radiating  an- 
teriorly in  a  girdle  shaped  manner.    For  the  past  four  weeks  the  abdomen 

='  See  Cases  23,  24,  25. 

304 


CARCINOMA    OF    THE    GALL-BLADDER  :J()5 

is  enlarged,  since  then  tiie  patient  has  become  greatly  emaciated.  At 
present  (January,  1900)  there  is  no  pain,  only  toward  the  end  there  was 
pain  in  the  right  half  of  the  abdomen.    Continued  anorexia. 

ad  7. — Icterus  of  mild  degree.  Ascites  and  bilateral  hydrothorax 
(worse  on  the  left  side).  Numerous  hard  nodules  can  be  felt  in  the  re- 
gion of  the  gall-bladder  and  in  the  right  hepatic  lobe ;  the  right  hepatic 
lobe  is  drawn  out  into  a  "corset  lobe"  and  marked  off  by  a  deep  "corset 
groove."  Peritoneal  friction  in  the  region  of  the  gall-bladder.  Arythmia 
without  bradycardia. 

Urine:  Bilirubin  negative;  urobilinogen  present. 

Blood:  13,000  leucocytes,  hemoglobin,  707c. 

No    itching    of    the    skin,    a    few    cutaneous    hemorrhages.      Retro- 
malleolar   edema.     Afebrile    course.     Lactic-acid   bacilli    and    stagnating 
remains  of  muscle  fibres  are  transiently  demonstrable  in  the  vomitus. 
ad  8. — Beginning:  September,  1899. 

Status   presens :  January   4,   1900. 
Autopsy:  January  23,  1900. 
Duration:  About  5  months, 
ad  9. — Autopsy    (Professor   Dr.    0.   Stoerk)  :   Fibrous    cancer   of 
the    gall-bladder    superimposed    on    a    cholelithiasis    (about    two    dozen 
small,  facetted,  dark  calculi  and  one  light  colored  in  the  neck  of  the  gall- 
bladder, as  big  as  a  dove's  Qgg)   with  regional  metastases   in  the  par- 
enchyma  of   the  liver   and   the  lymph-nodes   in    the   hilum   of   the   liver. 
The  hepatic  flexure  of  the  colon  is  adherent  to  the  gall-bladder.    Con- 
striction of  the  corresponding  portion  of  the  duodenum.    Hydrops,  as- 
cites, hydrothorax.   General  severe  icterus. 

Epicrisis:  The  beginning  of  the  disease  (anorexia,  nausea  toward 
meat)  bore  a  gastric  impress;  a  month  later  there  already  appeared 
biliar}'  congestion. 

The  very  rapid  course  of  the  disease  is  worthy  of  note:  death  five 
months  after  appearance  of  the  first  s3^mptoms. 

There  had  never  existed  any  painful  attacks  such  as  occur  with 
cholelithiasis ;  autopsy  disclosed  a  small,  contracted  gall-bladder  filled 
with  calculi. 

The  metastases  were  situated  in  the  region  immediately  surrounding 
the  gall-bladder,  the  left  hepatic  lobe  being  almost  entirely  free  from 
metastases,  this  latter  being  of  frequent  occurrence  with  carcinoma  of 
the  gall-bladder. 

The  duodenum  was  greatly  narrowed ;  during  life  there  had  been 
symptoms  of  stagnation,  lactic-acid  bacilli  al^o  being  demonstrable. 
The  ascites  had  been  so  considerable  tliat  distinct  palpation  was  possi- 
ble only  after  aspiration  of  the  fluid.  Seven  years  before  the  appearance 
of  the  cancerous  disease,  the  patient  being  60  years  old,  there  had  boon 
an  articular  rheumatism   for  3  months. 

Case  3. — A.  S.,  43  years,  M.    Machinist. 

ad   1. — Father  is   living  and  well. 
ad  3. — Has  had  typhoid. 


306  TUMORS    OF    THE    ABDOMINAL    VISCERA 

•ij  5. — One  day  in  September,  1900,  at  5  p.m.  severe  colicky 
pain,  without  apparent  cause,  in  the  inferior  abdominal  region,  accom- 
panied by  chill;  no  icterus.  Afterward  anorexia  for  two  or  three  days. 
One  month  later  (October,  1900)  icterus  appeared  and  the  patient 
noticed  slight  stabbing  pain  in  the  region  of  the  gall-bladder  (at  his 
work  was  compelled  frequently  to  stoop  and  also  to  brace  instruments 
against  the  region  of  the  liver).  Since  then  could  not  lie  on  the  left 
side  because  it  produced  a  sensation  as  if  something  in  the  abdomen  was 
drawn  over  to  the  left  side.  Appetite  good;  but  there  is  a  feeling  of 
fulness  in  the  stomach.  No  vomiting,  no  eructation,  meat  is  well  tol- 
erated. Bowels  regular,  daily  movement.  Despite  a  good  appetite  there 
is  emaciation  to  the  extent  of  3  kg.    Afebrile  course. 

ad  6. — Pain  in  the  back  on  stooping;  the  vertebral  column 
slightly  tender  on  pressure  between  the  shoulder-blades. 

ad  7. — Icterus  of  medium  degree.  The  gall-bladder  can  be  seen 
through  the  abdominal  wall  as  big  as  a  cherry ;  above  it  there  is  a  firai 
nodule  in  the  liver  tissue.  Liver  somewhat  enlarged  all  around,  with 
some  increase  in  consistency,  the  right  lobe  being  tender  on  percussion. 
No  edema  (December  11,  1900),  no  indications  of  a  hemorrhagic  dia- 
thesis. 

December  U),  1900:  Painful  swelling  in  tlie  bend  of  the  left  elbow, 
the  veins  in  that  locality  being  dilated  and  painful  (thrombosis  at 
autopsy!)  ;  similar  pain  over  the  right  lower  leg.  The  saphenous  vein  of 
the  left  lower  extremity  is  very  painful,  and  can  be  felt  as  a  cord; 
later  on,  severe  edema  of  the  left  lower  extremity  with  great  attenuation 
of  the  icteric  coloration  over  that  area;  mucli  cyanosis.  Circumference 
of  the  calf  on  the  right  side  33  cm,  the  thigh  on  the  left  side  49  cm,  the 
right  38  cm.  During  the  further  course  there  occurred  gangrene  of  the 
toes  of  the  left  foot. 

ad  8. — Beginning:    September,    1900. 

Status  presens:  December  11,  1900. 
Autopsy:  January  4,  1901. 
Duration:  About  4  months. 

ad  9. — Autopsy  (Professor  Dr.  0.  Stoerk)  :  Carcinoma  of  the 
neck  of  the  gall-bladder  with  metastases  in  the  liver  and  the  lymph- 
nodes  at  the  hilum  of  the  liver.  Tremendous  dilatation  of  the  biliary 
passages  and  severe  icterus.  Compression  of  the  inferior  vena  cava  by 
retroperitoneal  carcinomatously  infiltrated  lymph-nodes,  together  with 
thrombosis  of  the  inferior  vena  cava  and  both  crural  veins.  Beginning 
o-angrene  of  the  left  foot.  Severe  hemorrhage  from  the  nasal  mucous 
membrane.  The  gall-bladder,  as  big  as  a  plum,  is  filled  with  very  numer- 
ous concretions,  the  neck  being  !/>  cm  in  thickness ;  a  milky  secretion 
can  be  scraped  from  the  cut  surface. 

Epicrisis:  Also  in  this  case  the  clinical  duration  of  the  disease  is  a 
verv  short  one,  being  only  about  four  months.  The  attack  of  typhoid, 
referred  to  in  the  history,  may  in  its  day,  by  way  of  a  cholecystitis, 
have  o-iven  the  impulse  to  the  formation  of  biliary  calculi.  As  in  Cases 
1   and  2,   so   also   here,   the   previous   history   offers   no   clue   to   suspect 


CARCINOMA    OF    THE    GALL-RLADDKll  307 

gall-stone  colics.  The  first  attack  is  provoked  evidently  by  the  inci- 
pient development  of  the  cancer. 

The  development  of  a  painful  left  lateral  position  is  worthy  of  note, 
and  is  not  seldom  found  in  connection  with  affections  of  the  gall-bladder. 
The  metastasis  in  the  liver  was  very  slight,  the  organ  being  enlarged 
as  a  result  of  biliary  congestion,  and  therefore  felt  firm. 

Glandular  metastases  lead  to  the  compression  of  the  inferior  vena 
cava ;  the  latter,  as  well  as  the  veins  of  the  lower  extremity,  being  throm- 
bosed. 


Case  4. — L.  K.,  64  years,  M. 

ad  5.— Was  always  healthy  until  April  7,  1901. 

ad  6. — On  April  7,  1901,  early  in  the  morning  there  occurred 
sudden  pain  around  the  umbilicus,  lasting  twenty-four  hours,  associated 
with  pain  in  the  back  and  nausea;  three  weeks  later  the  urine  became 
dark  brown,  and  the  attending  physician  diagnosed  icterus.  Then  the 
yellow  discoloration  increased  in  intensity.  Since  the  appearance  of 
icterus  there  is  loss  of  appetite,  the  bowel  evacuations  are  frequently 
fluid.  Since  the  end  of  June,  1901,  the  pain  has  increased,  being  local- 
ized partly  in  the  region  of  the  umbilicus  and  partly  corresponding 
to  the  right  hepatic  lobe. 

ad  7. — Severe  icterus,  distinct  ascites,  great  emaciation.  Febrile 
course.  Liver  enlarged  downward  about  the  width  of  one  hand;  on  the 
right  side  below  the  costal  arch  nodules  can  be  felt,  corresponding  to  the 
location  of  the  gall-bladder  there  is  tenderness  to  pressure.  Spleen 
slightly  enlarged.    Severe  edema  behind  the  malleoli  and  over  the  tibias. 

ad  8. — Beginning:  April  7,  1901. 

Status  presens:  August  7,   1901. 
Autopsy:  August  21,"  1901. 
Duration :  4  to  5  months. 

ad  9. — Autopsy  (Professor  Dr.  H.  Albrecht)  :  Contracting  car- 
cinoma of  the  cystic  duct  encroaching  on  the  ductus  choledochus  and  great 
dilatation  of  the  gall-bladder.  Diphtheritic  cholecystitis.  Severe  icterus. 
Very  small  metastases  in  the  liver.  Ascites  and  bilateral  hydrothorax. 
Severe  hemorrhage  in  the  gastro-intestinal  canal  from  hemorrhagic  ero- 
sions in  the  stomach.   No  biliary  calculi. 

Epicrisis:  Similarly  as  in  Case  3  the  disease  in  this  instance  begins 
suddenly  with  an  attack  of  colic  lasting  twenty-four  hours,  which,  very 
likely,  is  to  be  interpreted  as  a  gall-bladder  colic  and  has  some  connec- 
tion with  the  development  of  cancer  in  the  neck  of  the  gall-bladder. 
Concretions  are  absent.  Autopsy  disclosed  an  enlarged  gall-bladder. 
Common  to  Cases  3  and  4  is  the  fact  that  the  icterus  does  not  im- 
mediately follow  the  initial  attack  of  pain,  but  sets  in  about  a  month 
later. 


808  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  5.— F.  Z.,  74  years,  M. 

ad   1.— Father  died  at  61  years  of  age. 

ad  5. — Was  always  healthy ;  three  years  ago  had  mild  gastric 
complaints  with  eructation. 

ad  6. — Since  the  middle  of  January,  1904,  attacks  of  cutting 
pain  in  the  right  hypochondrium ;  the  pain  comes  on  at  intervals  of  two 
to  three  hours,  and  is  worse  at  night.  For  the  past  two  weeks  the  pain 
has  been  particularly  intense,  with  now  and  then  mild  chills.  Since  the 
same  time  there  has  been  constipation.  From  the  beginning  of  the  dis- 
ease anorexia,  disinclination  toward  meat  and  vegetables,  predilection 
for  flour  and  milk  foods.  The  duration  of  the  icterus  is  not  known. 
Great  emaciation  since  the  beginning  of  the  disease;  vomited  onl}'  once, 
in  the  early  part  of  February  of  this  year. 

ad  7. — Icterus  gravis,  but  without  itching  of  the  skin  and  with- 
out hemorrhagic  diathesis.  No  ascites.  Liver  slightly  enlarged,  very 
tender  on  percussion  in  the  middle  line,  gall-bladder  not  palpable,  the 
j'egion  of  the  gall-bladder  not  tender  on  pressure.  Pulse  small,  ir- 
regular. Tonometer  (Gartner)  50  mm  Hg.  No  edemas.  Tempera- 
ture mostly  over  37°  C. ;  February  9,  38.1°  C. ;  February  15,  39.6°  C. 
Death  early  on   the  morning  of  February  16. 

ad  8. — Beginning:  Middle  of  January',  190-i. 
Status  presens:  February  14,  1904. 
Autopsy :  February  16,   1904. 
Duration:  About  1   month. 

ad  9. — Autopsy  (Professor  Dr.  O.  Stoerk)  :  Papillary  carcinoma 
of  the  gall-bladder,  which  was  diminished  in  size,  and  isolated  metastases 
in  the  ductus  ciioledochus  at  the  juncture  with  the  cystic  duct.  Cholan- 
gitic  abscesses  especially  in  the  left  hepatic  lobe. 

Epicrisis:  The  subjective  symptoms  of  the  disease  made  their  first 
appearance  about  one  month  prior  to  death,  and  analogous  to  observa- 
tions in  Cases  3  and  4  they  consisted  of  colicky  pain  in  the  hepatic 
region,  which  after  the  manner  of  colicky  pain  was  attended  by  noc- 
turnal exacerbations. 

Nothing  could  be  said  with  certainty  regarding  the  duration  of  the 
icterus.  The  chills  and  the  febrile  course  were  explained  anatomically 
by  the  cholangitic  abscesses  in  the  left  hepatic  lobe. 

The  beginning  of  the  symptoms  was  associated  with  meat  anorexia. 
As  in  Case  4  no  concretions  could  be  found. 

Attacks  similar  to  cholelithiasis  and  occurring  for  the  first  time  in 
old  age  are  always  suspicious  of  carcinoma  of  the  gall-bladder. 


Case  6.— S.  W.,  46  years,  F. 

ad  1. — Father  living,  79  years  old,  is  healthy. 

ad  3. — Has  had  no  infectious  diseases. 

ad  5.^Frail  in  childhood,  but  otherwise  healthy;  later  on  anemic; 
is  said  to  have  expectorated  foamy  blood  in  the  summer  of  1903,  like- 
wise in  1902. 


CARCINOMA    OF    THE    GALL-BLADDER  JJ09 

ad  6. — In  tlie  fall  of  1903  general  indisposition,  easily  fatigued, 
anorexia.  Two  weeks  before  Christmas,  1903,  her  color  became  very 
yellow  for  several  days,  accompanied  by  very  frequent  vomiting  of  white 
mucous  masses.     There  was  disgust  toward  meat  and  soup. 

In  January,  1904,  pain  set  in  in  the  right  h;df  of  the  abdomen, 
where  a  swelling  could  be  noticed.  The  urine  became  darker,  the  bowels 
remained  regidar  as   formerly. 

In  May,  1904',  edemas  appeared  in  the  lower  extremities. 

ad  7. — No  icterus.  The  right  lobe  of  the  liver  drawn  out  into  a 
"corset  lobe,"  downward  as  far  as  the  ileocecal  region ;  this  portion  of 
the  liver  very  hard,  uneven,  the  border  being  blunt  and  indented.  The 
tumor-mass  permits  of  ballottcment  from  the  right  flank  to  the  front. 
"Corset  groove"  just  underneath  the  costal  arch,  where  also  peritoneal 
friction  (snow  creaking)  can  be  felt  and  a  distinct  knot  with  a  depres- 
sion, can  be  demonstrated.  Pale,  soft  edema  in  the  lower  extremities 
and  at  the  sacrum.     Temperature  mostly  between  38°  C.  and  39°  C. 

Urine:  Continued  strong  diazo  and  aldehyde  reaction;  no  bilirubin. 

Blood:  24,600  leucocytes,  2,100,000  erythrocytes, 
ad  8. — Beginning:  Autumn,  1903. 

Status  presens :  June  6,  1904. 
Autopsy:  June  18,  1904. 
Duration  :  About  9  to  10  months, 
ad  9. — Autopsy   (Docent  Dr.  J.  Bartel):  Carcinoma  of  the  gall- 
bladder,  originating   in   the   fundus    (gall-bladder   small,    full    of   calculi, 
which  partly  also  occupy  the  cystic  duct)  ;  tremendous  enlargement  down- 
ward   of   the    right    hepatic    lobe    (metastases!).      Tuberculosis    of   both 
pulmonary  apices  with  induration. 

Epicrisis:  Though  the  characteristic  hepatic  symptom  of  abnormal 
skin  discoloration,  i.  e.,  icterus,  was  absent,  the  abnormally  dark  color 
of  the  urine,  together  with  the  strong  aldehyde  reaction,  must,  from 
the  very  beginning,  have  suggested  the  possibility  of  an  hepatic  disease. 

The  course  was  a  highly  febrile  one  and  was  accompanied  by  a 
strong  diazo  reaction,  which  can  probably  be  traced  to  an  associated 
infection  of  the  biliary  passages,  the  same  as  the  leucocytosis  (24,600). 

Identification  of  the  tumor-mass  as  part  of  the  liver  was  not  without 
difficulty,  as  it  was  separated  from  the  liver  by  a  deep  "corset  groove," 
so  that  for  a  time,  on  account  of  its  proximity  to  the  true  pelvis,  there 
was  even  thought  of  a  possible  ovarian  tumor.  "Corset  lobes"  are 
frequently  met  with  in  connection  with  cholelithiasis,  hence  also  car- 
cinoma of  the  gall-bladder,  and  I  consider  them  partly  as  congenital, 
similar  to  the  "indented"  tongue,  which,  according  to  my  experience, 
is  frequently  observed  with  cholelithiasis.  Here  also  the  metastases  are 
regional,  affecting  particularly  the  neighborhood  of  the  gall-bladder.  An 
attack  of  cholelithiasis  with  rapidly  retrogressing  icterus  ushers  in  the 
clinical  picture ;  as  so  frequently,  it  is  the  first  attack  of  gall-stone  colic, 
the  disease  being  latent  until  the  appearance  of  the  cancer. 

The  gastric  symptoms  that  deserve  note  are:  Disgust  toward  meat 
and  soup,  and  mucous  vomiting. 


310  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  7.— M.  S.,  54  years,  F. 

ad  1. — Both  parents  died  from  weakness  of  old  age. 
ad  3. — As  a  child  had  t^'phoid,  was  otherwise  healthy. 
ad  5. — Two  years  ago  (1900)  at  10  p.  m.,  after  eating  bad  butter, 
there  occurred  severe  cutting  pain  in  the  epigastrium,  somewhat  more 
to  the  right  and  radiating  into  the  back;  chill,  biliary  vomiting;  could 
not  lie  on  the  right  side.  On  the  second  day  the  urine  was  dark  brown, 
on  the  third  day  the  sclerae  became  yellow.  On  the  right  side  under- 
neath the  costal  arch,  a  resistance  could  be  felt  which  was  as  big  as  a 
fist.  The  icterus  lasted  three  weeks,  after  which  there  were  no  further 
complaints. 

ad  6. — In  the  beginning  of  November,  1902,  after  eating  a  pear 
there  occurred  severe  pain  in  the  epigastrium,  radiating  to  the  right; 
the  patient  could  not  keep  herself  erect,  could  not  walk.  No  chill.  The 
epigastrium  enlarged,  and  underneath  the  right  costal  arch  there  was  a 
palpable  swelling  which  was  painful  on  pressure.  The  urine  was  dark  red. 
ad  7. — December  23,  1902:  Subicteric  discoloration.  The  right 
hepatic  lobe  extends  far  downward,  in  the  middle  line  it  extends  midway 
between  the  umbilicus  and  xiphoid  process ;  the  border  of  the  liver  is 
very  firm.  Spleen  hard,  extending  to  the  costal  arch.  Liver  very  sensi- 
tive to  pressure. 

Urine:  No  urobilinogen. 

January  16,  1903:  The  liver  is  tremendously  enlarged,  very  firm,  sur- 
face uneven.  Friction  can  be  distinctly  felt  over  the  left  hepatic  lobe,  pain 
on  pressure  and  on  deep  breathing.  Venous  dilations  in  the  epigastrium. 
Pulse  small,  frequent.     Pvdenia  behind  the  malleoli  and  at  the  sacrum. 

Urine:  Abundant  urobilinogen. 

Stomach  contents:  One  per  cent.  HCl. 

Toward  the  end  respiration  became  slow,  the  pulse  raj)id.  Suhnormal 
temperatures  during  the  last  days. 

ad  8. — Beginning:  November,  1902   (?). 

Status  prcscns:  December  23,   1902. 
Autopsy :  January  23,  1903. 
ad  9. — Autopsy    (Docent    Dr.    A'.    Landsfeiner) :    Polypoid    car- 
cinoma of  the  gall-bladder,  which  was  filled  with  calculi.     Diffuse,  nodular 
metastases  in  the  liver  ("corset  lobe"). 

Epicrisis:  Two  years  before  death  there  occurred  a  typical  attack  of 
gall-stone  colic ;  the  second  attack  occurred  about  two  months  before 
death.  This  attack  ushers  in  the  clinical  period  of  the  cancer.  At  the  first 
examination  there  could  have  been  doubt  as  to  whether  we  were  not  deal- 
ing with  a  cirrhotic  disease  because  of  a  synchronously  existing  splenic 
tumor.  After  a  short  period  of  observation,  however  (December  23  to 
January  16),  the  progressiveness  of  the  manifestations  was  apparent  and 
pointed  to  a  malignant  process. 

Urobilinogen,  which  was  originally  absent  from  the  urine,  appeared 
in  large  quantities,  the  liver  enlarged  and  became  distinctly  uneven, 
peritoneal  friction  appeared  over  the  left  hepatic  lobe,  findings  which  are, 
in  and  of  themselves,  unusual  with  cirrhoses. 


CARCIXO:\IA    OF    THE    GALL-BLADDER  311 

The  gastric  secretion  of  HCl  persisted,  neither  was  there  any  other 
o-round  for  suspecting-  a  })i  iniary  gastric  cancer.  On  tlie  other  hand  one 
could  with  great  probability  infer  from  the  history  the  existence  of  a 
cholelithiasis  (after  typhoid?). 

The  configuration  of  the  liver,  together  with  the  downward  extension 
of  the  right  lobe,  corresponded  to  a  "corset  lobe,"  which  is  so  frequently 
concomitant  with  the  presence  of  gall-stones.  The  patient  was  descended 
from  long-lived  parents. 

Case  8.— K.  B.,  67  years,  F. 

ad  1. — Mother  lived  to  be  76  years  old;  the  father  also  attained  an 
old  age. 

ad  2. — Was  healthy  until  52  years  of  age ;  at  that  time  she  was 
taken  sick  Avith  a  febrile  articular  rheumatism,  at  the  beginning  in  the 
neck,  later  localized  particularly  in  the  knee-joint.     Duration:  6  months, 
ad  3. — No  infectious  diseases  in  childhood. 

ad  6. — In  September,  1904,  while  lifting  a  load,  there  occurred 
cramp-like  pain  in  the  right  side  of  the  abdomen.  After  several  days  the 
urine  was  dark,  stool  light,  skin  yellow.  Anorexia  since  the  beginning  of 
the  disease  but  without  eructation  or  vomiting,  severe  emaciation.  Before 
the  disease  the  bowels  were  constipated,  now  they  are  more  regular. 

ad  T. — Icterus  of  high  degree ;  severe  ascites.  Soft  edemas  in  the 
lower  extremities  and  at  the  sacrum.  Liver  slightly  enlarged.  INIildly 
febrile  course. 

Feces:  Many  neutral  fat  globules  and  soap  needles.  No  urobilinogen. 
Urine:  No  indican  reaction. 
Blood:  4,000  leucocytes. 

January  19,  1905 :  Profuse  hematemesis  and  appearance  of  perito- 
nitic  symptoms. 

ad  8. — Beginning:  September,  1904. 

Status  prcscns:  January  10,  1905. 
Autopsy:  January  21,  1905. 
Duration :  4  to  5  months. 
ad  9. — Autopsy    (Docent    Dr.    A'.    Landsieiner)  :    Papillary    car- 
cinoma  in   the   fundus   of  the   gall-bladder   (gall-bladder   full   of  calculi, 
calculi  also  at  the  end  of  the  ductus  choledochus)  ;  abscesses  in  the  left 
hepatic  lobe,  one  of  these  abscesses  perforating  into  the  abdominal  cavity: 
peritonitis.      Metastases    ad    portam    hepatis.      Icterus    gravis.      Healed 
tuberculosis  of  the  pulmonary  apices. 

Epicrisis:  Here  again  we  find  longevity  of  the  parents!  At  the  age 
of  52  there  occurred  for  the  first  time  a  severe  attack  of  articular  rheuma- 
tism, which  would  suggest  a  metabolic  anomaly  as  the  cause.  The  first 
attack  of  cholelithiasis  (four  months  prior  to  death)  was  probably  elicited 
by  the  carcinomatous  disease  in  the  gall-bladder.  The  cancer  mobilizes 
the  calculi !  The  severe  icterus  is  due  to  the  complete  occlusion  of  the 
ductus  choledochus  b}'  concretions ;  therefore  there  resulted  a  greatly 
disturbed  fat  reduction  with  neutral  fat  in  the  stools  and  complete  absence 
of  urobilinogen.      The   secondary   abscess   formation   is   accompanied   by 


312  TUMORS    OF    THE    ABDOMINAL    VISCERA 

leukopenia    (4,000),  and   gives  rise   to   an   acute  peritonitis  which  leads 
to  hematemesis. 

The  disease  began  and  ended  with  anorexia. 

Case  9.— R.  T.,  52  years,  F. 

ad   1.- — Father  died  from  weakness  of  old  age,  mother  died  at  65. 

ad  3. — Has  had  no  infectious  diseases. 

ad  4. — Constipation  since  childhood. 

ad  5. — Was  always  healthy  ;  has  had  eleven  confinements.  [Meno- 
pause ten  years  ago.  For  several  ^^ears  she  has  had  frequent  attacks 
of  cramps  in  the  pit  of  the  stomach  at  intervals  of  several  daj^s  to  a 
few  weeks,  not  influenced  by  ingestion  of  food.  P'or  the  past  year  these 
attacks  have  ceased. 

ad  6. — In  October,  1904,  there  began  pain  vinderneath  the  right 
costal  arch  and  in  the  back.  The  appetite  disappeared,  the  patient 
emaciated,  and  took  on  a  pale  appearance.  Vcr^^  severe  lumbar  pain, 
somewhat  worse  on  the  right  side;  decrease  of  pain  after  bowel  evacua- 
tions. 

ad  7. — [Moderate  jaundice,  diminishing  toward  the  end,  pale  facial 
color.  The  right  lobe  of  the  liver  drawn  out  into  "corset  lobe,"  extend- 
ing far  downward  and  liaving  a  somewhat  firm  consistence;  surface,  how- 
ever, is  smootli.  A  tumor-mass,  as  big  as  a  nut,  can  be  felt  underneath 
the  costal  arch.  In  palpating  the  hepatic  border  from  above  the  gall- 
bladder can  be  felt  at  the  under  surface  of  the  liver;  no  appreciable  en- 
largement demonstrable.     No  edemas.     IMild  febrile  course. 

Urine:  Strong  aldchvde  reaction  ;  nnich  sediment  lateritium. 
Blood:  12,000  leucocytes. 

ad  8. — Beginning:  October,  1904. 

Status  presens:  February  24,  190.5. 
Autopsy:  April  13,  1905. 
Duration  :  6  to  7  months. 

ad  9. — Autopsy  (Professor  Dr.  0.  Stoerk)  :  Carcinoma  of  the  gall- 
bladder and  of  the  ductus  choledochus,  with  contraction  and  occlusion 
of  the  cystic  duct.  Purulent  hydrops  of  the  gall-bladder  (gall-bladder 
full  of  concretions)  ;  isolated  metastases  in  the  "corset  lobe."  Omental 
metastases  (corresponding  to  the  tumor  palpable  on  the  left  side).  Cancer 
thrombi  of  the  ramifications  of  the  portal  vein  in  the  liver.  Hydrops, 
ascites.  General  icterus.  IMultilocular  cyst,  the  size  of  a  child's  head, 
belonging  to  the  right  ovary. 

Epicrisis:  Longevity  of  the  parents;  never  any  infectious  diseases; 
always  in  good  health !  It  seems  to  me  that  these  three  factors  are  pre- 
disposing to  malignant  disease.  For  several  years  there  were  frequent 
attacks  of  gall-stone  colics,  which  suddenly  ceased  about  one  year  before 
death  from  cancer  of  the  gall-bladder.  Just  a  few  months  before  death 
gall-bladder  pain  again  set  in.  The  jaundice  diminished  somewhat 
toward  the  end  of  the  disease ;  a  palpable  tumor  on  the  left  side  under- 
neath the  costal  arch  was  due  to  a  metastasis  in  the  omentum.  The  con- 
tinuation of  a  cholelithiasis  and  a  "corset  lobe"  was  characteristic  also 


CARCINOMA    OF    THE    GALL-BLADDER  313 

ill  this  case.     The  firm  consistence  of  the  tumor  was  much  more  dependent 
on  connective  tissue  induration  than  metastases. 

Case  10.— L.  G.,  46  years,  M. 

ad  1. — Mother  died  of  cancer,  one  brother  died  of  pulmonary 
tuberculosis. 

ad  3. — Has  liad  no  infectious  diseases  of  childhood.  In  1887  had 
a  soft  chancre  with  suppuration   of  glands. 

ad  4. — Bowels  always  regular ;  often  had  heartburn,  so  much  so 
that  he  always  carried  sodium  bicarbonate  with  him. 

ad  5. — Otherwise  was  always  healthy.  Eighteen  years  ago,  when 
twenty-eight  years  of  age,  there  occurred  sudden  cramp-like  pain  in  the 
region  of  the  liver;  an  inflammation  of  the  liver  capsule  was  diagnosed. 

ad  6. — Since  the  end  of  March,  1905,  there  has  been  pain  under- 
neath the  right  costal  arch  when  walking  rapidly,  on  coughing,  when 
lying  on  the  right  side  and  sitting  up.  Formerly  had  frequent  heart- 
burn one  hour  after  meals,  especially  after  eating  sour  or  spicy  foods. 
Since  the  beginning  of  the  disease  there  has  been  none  of  these  symptoms ; 
appetite  good  even  now.  Despite  this  the  patient  has  emaciated  to  the 
extent  of  13  kg  during  the  past  few  weeks.  The  former  color  of  the 
face  has  become  pale ;  the  urine  has  become  dark. 

ad  7. — No   icterus ;   sallow   complexion.     Liver  exhibits   a   "corset 
lobe,"   is   enlarged,  hard,   uneven,   everywhere   tender   to   pressure ;   peri- 
hepatic   friction    can   be    felt.      The    gall-bladder   is    not    palpable.      No 
edemas.     Febrile  course  with  temperatures  over  38°  C. 
Urine:  Aldehyde   reaction  distinctly  positive. 
Blood:  24,900  leucocytes. 

ad  8. — Beginning:  End  of  March,  1905. 
Status  presens :  May  2,  1905. 
Autopsy:  June  15,  1905. 
Duration:  21/0  months. 

ad  9. — Autopsy  (Professor  Dr.  0.  Stoerk)  :  Carcinoma  of  the  gall- 
bladder with  regional  diffuse  infiltration  of  the  liver.  Lithiasis  of  the 
gall-bladder  with  impaction  of  calculus  in  the  neck. 

Epicrisis:  Aside  from  an  "inflammation  of  the  liver  capsule"  (?)  at 
28  years  of  age,  the  patient  had  always  been  well,  except  that  he  experi- 
enced frequent  heartburn.  This  symptom  disappeared  with  the  coming 
of  the  cancer  (decrease  of  HCl  secretion.'').  The  latter  is  ushered  in  with 
pain  in  the  region  of  the  liver,  the  pain  being  easily  influenced  mechani- 
cally (sitting,  rapid  walking,  coughing,  lying  on  the  right  side). 

It  might  be  due  partly  to  the  objectively  demonstrable  fibrinous 
perihepatitis.     The  entire  liver  is  very  sensitive  to  pressure. 

The  perihepatitis  is  probably  of  cholangitic  origin,  as  well  as  the 
fever  and  the  high  leucocytosis  (24,900). 

The  appetite  remained  good  on  account  of  which  the  emaciation  was 
so  much  more  significant.  The  liver  shoAved  the  formation  of  a  "corset 
lobe."  Icterus  was  absent;  the  dark  color  of  the  urine  was  due  to 
urobilin. 


314  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  11.— M.  M.,  57  years,  F. 

ad  5. — Was  always  healthy. 

ad  6. — Since  March,  1906,  supposedly  after  a  dietetic  error 
anorexia,  nausea  and  constipation.  Great  feeling  of  thirst,  continuous 
headaches. 

ad  7. — No  icterus.  Stomach  greatly  dilated,  visible  gastric  peri- 
stalsis, in  connection  with  which  there  appear  bulgings  to  the  right  and  left 
of  the  umbilicus.  Loud  splashing  on  succussion  of  the  abdomen.  No 
edemas.  Copious  vomiting;  abundant  growth  of  sarcina?.  Total  acidity 
70%,  HCl  acidity  38%,  1-10  N.  NaOH. 
ad  8. — Beginning:  March,   1906. 

Status  presens:  April  27,  1906. 
Autopsy:  May  3,  1906. 
Duration:  2   months, 
ad  9. — Autopsy   (Professor  Dr.  A.  Glion)  :  Fibroid  carcinoma  of 
the  gall-bladder  (gall-bladder  contracted,  containing  one  calculus)   only 
regionally  infiltrating  the  liver;  encroaching  on  the  pylorus  and  severely 
constricting  it ;  slight  stenosis  at  the  hepatic  flexure  of  the  colon.   Chronic 
endarteritis. 

Epicrisis:  This  is  one  of  those  cases  of  cancer  of  the  gall-bladder 
in  which  the  original  disease  is  easily  misinterpreted.     Icterus  is  absent. 

Gastric  symptoms,  namely  those  of  a  pyloric  stenosis,  dominate  the 
clinical  picture:  Growth  of  sarcinae,  persistent  HCl  secretion,  visible 
gastric  peristalsis. 

This  makes  one  think  of  cicatricial  constriction  of  the  pylorus  (after 
an  ulcer),  or  even  of  a  cancer  of  the  pylorus. 

At  any  rate  the  short  duration  of  the  symptoms  in  the  above  case 
was  very  striking. 

A  cicatricial  constriction  of  the  pylorus  of  similar  intensity  (follow- 
ing an  ulcer)  would  lead  us  to  expect  symptoms  dating  back  a  number 
of  years. 

The  absence  of  colics  from  pyloric  constriction,  despite  persistence  of 
HCl  secretion,  was  remarkable  because  the  acid  secretion  usually  exerts 
a  painful  influence  on  the  pylorus  when  it  has  undergone  cicatricial  or 
ulcerative  changes. 

The  synchronous  presence  of  a  stenosis  of  the  hepatic  flexure  of  the 
colon  also  was  suggestive  of  a  fibrous  cancer  of  the  gall-bladder. 

Finally  it  is  possible  that  a  very  careful  examination  of  the  region 
of  the  gall-bladder  and  the  adjacent  area  of  the  liver  might  lead  one  on 
the  right  track. 

Case  12.— F.  K.,  54  years,  F. 

ad   1. — No  hereditary  tendency  toward  carcinoma. 

ad  3. — Has  had  no  infectious  diseases. 

ad  4. — Four  3'ears  ago  had  a  typical  attack  of  gall-stone  colic; 
jaundice  two  days  after  the  attacks,  lasting  two  weeks. 

ad  6. — In  the  summer  of  1907  the  clothes  became  too  big.  At 
Christmas,    1907,    while   walking   the    patient    experienced    a    feeling   of 


CARCINOMA    OF    THE    GALL-BLADDER  315 

fulness  and  tension  in  the  region  of  the  liver;  soon  after  there  occurred 
severe  pain  in  the  same  phice,  especially  at  night.  The  abdomen,  as 
well  as  the  right  leg,  gradually  enlarged.  Since  the  middle  of  January, 
1908,  the  patient  has  been  bedridden.  No  gastro-intestinal  symptoms, 
ad  7. — No  jaundice;  pale  color  of  the  face.  Ascites  of  moderate 
degree.  Liver-shaped  like  a  "corset  lobe,"  very  much  enlarged,  very  firm, 
sensitive  to  pressure.     Edema  of  the  right  leg  and  also  of  the  sacrum. 

July  2:  Tarry  black  stools. 

Urine:  Aldehyde  reaction  positive, 
ad  8. — Beginning:  Summer  of  1907. 

Status  presens :  February  25,  1908. 
Autopsy :  March  9,  1908. 
Duration :  7  to  8  months. 
ad  9. — Autopsy   (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Car- 
cinoma of  the  neck  of  the  gall-bladder  supervening  on   a   cholelithiasis. 
Numerous    confluent    metastases,    especially    in    the    right    hepatic    lobe. 
Congestion  of  the  mucosa  of  the  large  intestine.    Moderate  ascites.    Cal- 
careous tubercular  focus  in  the  upper  lobe. 

Epicrisis:  The  previous  history  mentions  a  typical  attack  of  cholelith- 
iasis. Objective  examination  discloses  "corset  lobe"  shape  of  the  liver, 
enlargement  and  hardening  of  the  organ  without  jaundice  and  with 
ascites.  A  liver  tender  to  pressure  is  a  rare  finding  in  cirrhosis  of  Laennec 
but  frequently  found  in  cancer  of  the  liver.  Likewise  the  combination 
of  enlarged  liver  and  ascites  is  rare  in  cirrhosis  but  frequent  in  cancer. 

In  this  case  also  the  right  lobe  of  the  liver  shares  in  the  metastases 
to  a  far  greater  extent  than  the  left  lobe. 

The  terminal  melena  must  be  looked  upon  as  a  symptom  of  con- 
gestion (cardiac  insufficiency  and  congestion  of  the  portal  vein  as  a  result 
of  carcinoma  of  the  liver). 

Autopsy  disclosed  no  evidence  of  an  ulcerative  process  in  the  gastro- 
intestinal tract. 

Case  13.— M.  S.,  74  years,  F. 

ad  6. — Sick  since  September,  1907;  since  then  has  become  greatly 
emaciated ;  of  late  has  taken  only  milk  and  soup ;  complains  of  severe 
cough. 

ad  7. — No  icterus ;  pale  facial  color.  Gall-bladder  palpable,  soft ; 
the  adjacent  portion  of  the  liver  is  exceedingly  firm,  sensitive  to  pressure, 
a  nodule  as  big  as  a  cherry  can  be  felt  in  the  organ.  Soft  edema  on  the 
dorsal  surfaces  of  the  feet  and  behind  the  malleoli. 

Urine:  Traces  of  an  aldehyde  reaction.  Dyspnea  and  orthopnea; 
small,  rapid  pulse.     Foamy,  fetid  sputum. 

ad  8.^ — Beginning:  September,  1907. 
Status  presens:  April,  1908. 
Duration :  About  7  months. 

ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Sehlagenhnufer)  :  Car- 
cinoma of  the  gall-bladder  (cholelithiasis!)  invading  the  adjacent  liver 
tissue;  nodule-shaped   metastases   in   the  left   hepatic   lobe.      Old   apical 


316  TUMORS    OF    THE    ABDOMINAL    VISCERA 

tuberculosis;  fetid  bronchitis.    Infiltration  of  the  right  lower  lobe,  where 
there  is  a  gangrenous  area.    Arteriosclerotic  contracted  kidney. 

Epicrisis:  Also  this  case  ran  its  course  without  icterus.  It  was  only 
the  fact  that  the  carcinomatous  infiltration  and  the  formation  of  a 
cancer  nodule,  confined  to  the  immediate  proximity  of  the  enlarged  gall- 
bladder, which  called  to  mind  the  possibility  of  a  carcinoma  of  the  gall- 
bladder. 


Case  14.— J.  P.,  63  years,  F. 

ad  6. — In  April,  1908,  was  taken  suddenly  with  colicky,  severe 
pains  in  the  abdomen.  The  attacks  of  cramps  often  were  of  but  a  few 
minutes'  duration ;  during  the  attacks  the  abdomen  became  larger  and 
harder  and  there  occurred  lively  noises  which  the  patient  compared  to 
the  "running  of  water."  Since  then  these  attacks  have  recurred  often, 
but  without  pains.  The  bowels  move  daily  just  as  formerly.  Appetite 
is  bad.     Great  emaciation  during  the  past  few  weeks. 

ad  7. — No  jaundice.  Very  great  emaciation  and  munnnification. 
At  times  very  lively  intestinal  peristalsis  (not  painful),  loops  of  small 
intestine  appearing  first  around  the  umbilicus  and  the  ascending  colon 
coming  into  plain  view  toward  the  last.  The  peristalsis  ends  at  the 
hepatic  flexure.  In  the  latter  place  a  large  and  exceedingly  firm  swell- 
ing can  be  felt  at  the  border  of  the  liver.  The  right  flank  bulges,  is  very 
rigid,  the  left  flank  is  depressed.  Bigeminal  pulse.  Severe  edema  at  the 
sacrum. 

Fece.i:  Small  scybala  ;  blood-coloring  material  negative, 
ad  8. — Beginning:  April,  1908. 

Status  presens:  May  8,  1908. 
Autopsy:  May  10,  1908. 
ad  9.-^Autopsy  (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Fi- 
brous carcinoma  of  the  gall-bladder  (cholelithiasis).  Adhesions  to  the 
hepatic  flexure  leading  to  constriction  of  the  lumen  of  the  bowel.  Hyper- 
trophy and  dilatation  of  the  entire  small  intestine  and  the  ascending 
colon. 

E picrisis :  This  case  is  a  parallel  to  Observation  No.  11.  As  in  that 
case,  without  icterus,  as  a  result  of  fibrous  cancer  of  the  gall-bladder 
there  supervened  the  greatest  constriction  of  the  pylorus,  so  here  there 
developed  great  constriction  of  the  colon  in  the  region  of  the  hepatic 
flexure.  Here  also  the  symptoms  date  back  only  a  short  time,  the  stenosis 
apparently  having  been  compensated  for  a  long  time. 

The  rigidity  of  the  ascending  colon,  which  can  easily  be  recognized 
by  mere  inspection  of  the  protuberant  coils,  is  worthy  of  note. 

The  histor}^  does   not   reveal  any   attacks   of  cholelithiasis. 

Case  15.— F.  L.,  77  years,  F. 

ad  6. — Since  the  middle  of  April  there  have  been  stomach  com- 
plaints; anorexia  and  a  feeling  of  pressure  in  the  epigastrium.     After 


CARCINOMA    OF    THE    GALL-BLADUER  lUl 

four  weeks  there  was  a  siulden  appearance  of  jaundice.  Tlie  former 
regular  bowel  movements  were  now  followed  by  constipation.  The  patient 
never  suffered  from  colicky  pains. 

ad  7. — Severe  icterus.  Liver  not  enlarged;  the  portion  of  the 
hepatic  border  in  the  region  of  the  gall-bladder  is  of  a  particular  hard- 
ness, and  in  the  gall-bladder  a  facetted  concretion  can  be  felt.  Dis- 
tinctly visible  gastric  peristalsis  and  splashing  in  the  stomach.  Transient 
temperature  elevatfons  over  38°  C. 

Feces:  No  neutral  fat  globules. 

Urine:  Indican  reaction   (Obermayer)   negative  after  repeated  tests, 
ad  8.— Beginning:  Middle  of  April,  1908. 
Status  presens:  May,  1908. 
Autopsy:  May  21,  1908. 
ad  9. — Autopsy   (Pros.  Professor  Dr.  Fr.  Schlagenhaufer) :  Con- 
tracting  carcinoma   of   the   gall-bladder;    cholelithiasis.      Carcinomatous 
infiltration  of  the  duodenum  and  great  constriction  of  same.     Pancreas 
free.     Severe  jaundice. 

Epicrisis:  As  a  connnon  cause  for  the  syndrome  "visible  gastric  peri- 
stalsis and  severe  icterus"  there  entered  into  first  consideration  a  pancreas 
or  gall-bladder  affection.  Carcinoma  of  the  pylorus  is  only  very  ex- 
ceptionally accompanied  by  great  jaundice;  carcinoma  of  the  duodenum 
is  a  rarity. 

Objective  examination  revealed  an  abnormal  consistence  of  the  hepatic 
border  corresponding  to  the  gall-bladder ;  on  palpation  a  facetted  con- 
cretion could  be  demonstrated  in  the  gall-bladder.  Absence  of  indican 
reaction — even  without  a  lesion  of  the  pancreas — is  not  a  rare  finding 
with  icterus  gravis. 


Case  16.— N.  N.,  71  years,  F. 

ad  1. — One  sister  died  of  "abdominal  cancer,"  another  of  cancer  of 
the  uterus. 

ad  6. — On  February  24,  1905j  after  the  patient  had  suffered  a  fall 
on  her  back  a  swelling  was  noticed  in  the  right  half  of  the  abdomen ;. 
seven  weeks  later  there  appeared  severe  pain  in  the  back,  radiating  on 
both  sides  into  the  epigastrium.     Duration :  About  ten  days.     Anorexia. 

Toward  the  end  of  September,  1905,  the  patient's  attention  was 
called  to  the  existence  of  jaundice. 

Christmas,  1905 :  Severe  colicky  pains  with  diarrhea,  stool  whitish ; 
since  then  the  jaundice  is  said  to  have  diminished.  In  January,  1906,. 
severe  itching  of  the  skin. 

March  10,  1906:  Liver  enlarged,  very  hard,  surface  uneven.  Spleen 
greatly  enlarged. 

June  12,  1906:  Occasional  pain  in  the  right  half  of  the  abdomen. 
Sitting  up  causes  great  pain  in  the  region  of  the  liver.  Spleen  greatly 
enlarged.  Edema  of  the  legs.  Continued  fever  ranging  between  37°  C^ 
and  40°  C. 

Blood:  16,400  Icucoc^^tes. 


318  TUMORS    OF    THP:    ABDOMINAL    VISCERA 

ad  8, — Beginning:  February,  1905. 
Autopsy :  June,  1906. 
Duration :  1  year,  5  months, 
ad  9. — Autopsy:  Primary  carcinoma  of  the  gall-bladder  with  per- 
foration  into   the   duodenum.      Suppurative   articular   inflammation    (by 
metastasis  from  the  suppurative  area  around  the  gall-bladder). 

Epicrisis:  A  distinct  splenic  tumor  and  varying  icterus,  in  connec- 
tion with  a  diffuse  enlargement  and  increased  consistence  of  the  liver, 
for  a  time  suggested  the  possibility  of  a  biliary  cirrhosis. 

Aside  from  the  age  of  the  patient,  at  which  biliary  ciri'hosis  count 
among  the  great  rarities,  the  entire  ensemble  of  symptoms  spoke  in  favor 
of  a  carcinomatous  process.  The  splenic  tumor  was  sufficiently  ex- 
plained by  the  chronic  icterus  and  the  severe  cholangitic  infection,  the 
latter  also  accounting  for  the  varying  intensity  of  the  icterus. 

•  Toward  the  end  there  supervened  pyemic  joint  metastases  from  a 
pericholecystitic  purulent  focus.  The  gall-bladder  had  perforated  into 
the  duodenum. 


Case  17.— H.  G.,  46  years,  M.    Metal  pourer. 

ad  3. — At  11  years  of  age  had  ''abdominal  typhoid." 
ad  5. — During  military  service  had  dysentery;  was  healthy  until 
1882.  At  that  time  was  sick  with  anorexia,  heartburn,  feeling  of  gas- 
tric pressure;  bowels  constipated.  The  patient  was  strikingly  pale. 
Duration  of  the  disease:  About  two  years.  During  the  following  years 
felt  well  but  looked  pale. 

1894:  Lead  colic!    Rapid  convalescence. 

August,  1900:  Recurrence  of  stomach  trouble,  together  with  constipa- 
tion and  biliary  vomiting.     No  colic. 

ad  6. — In  the  beginning  of  February,  1901,  appearance  of  pain 
underneath  the  right  costal  arch,  on  coughing,  sneezing  and  on  motion. 
Since  then  the  patient  felt  exhausted ;  no  fever,  no  appreciable  emacia- 
tion. About  the  middle  of  February  the  abdomen  enlarged  somewhat, 
the  stools  became  lighter  in  color,  the  urine  darker.  Decreased  appetite 
for  meat ;  no  eructation  or  vomiting. 

ad  7. — Moderate  jaundice.  Abdomen  enlarged,  venous  dilatations 
in  the  epigastrium.  Liver  enlarged,  particularly  in  its  right  lobe,  ex- 
tremely firm,  painful  on  percussion,  especially  in  the  linea  alba.  Severe, 
soft  edema  in  the  lower  extremities  extending  up  to  Poupart's  ligament ; 
edema  of  the  scrotum.   Afebrile  course. 

ad  8.^ — Beginning:   Februar}',    1901. 

Status  presens:  March  11,  1901. 
Autopsy:  March  22,  1901. 
Duration:  About  2  months, 
ad  9. — Autopsy    (Professor  Dr.   A.   Ghon)  :   Cancer   of  the   neck 
of  the  gall-bladder  invading  the  liver  and  diffuse  cancerous  infiltration 
of  same.      Secondary   carcinoma   of  the  regional  lymph-nodes. 

Ejncrisis:   The   first   symptoms,  pain   in   the   gall-bladder   region   on 


CARCINOMA    OF    THE    GALL-BLADDER  319 

congliing,  sneezing  and  moving  about,  precede  death  by  hardly  two 
months. 

Venous  dilatations  in  the  epigastrium  point  to  the  disturl)ance  in  the 
portal  vein. 

Typhoid  infections,  even  without  the  connecting  link  of  calculus  for- 
mation, could  predispose  to  local  cancerous  disease  by  giving  rise  to  a 
chronic  cholecystitis. 

Case  18. — K.  D.,  46  years,  M.     Shoemaker. 

ad   1. — Father  died  of  tuberculosis. 

ad  4. — From  18  to  38  years  of  age  the  patient  frequently  had 
"stomach  cramps,"  especially  after  eating  sour,  strongly  seasoned  or 
gas-producing  foods.  Often  there  occurred  severe  burning  and  pressing 
pain  in  the  stomach,  about  one-quarter  to  two  hours  after  meals,  last- 
mg  half  an  hour;  in  order  to  gain  relief  the  patient  would  usually  lie 
with  his  belly  on  a  bolster;  frequent  pyrosis.  After  a  severe  attack  ki 
1894  the  attacks  are  said  to  have  ceased,  and  since  then  all  foods  have 
been  well  tolerate^!. 

ad  6. — Beginning  of  the  sickness  in  the  early  part  of  November, 
1901,  after  a  liberal  imbibition  of  wine.  During  the  following  days  loss 
of  appetite,  pain  after  eating  fat  meat.  The  pain  appeared  mostly 
one  to  two  hours  after  meals,  was  of  a  stabbing  and  pressing  char- 
acter, being  localized  especially  in  the  region  of  the  pylorus ;  they 
became  exacerbated  when  lying  on  the  right  side,  accompanied  by  a 
feeling  "as  if  everything  in  the  stomach  was  alive."  When  lying  on 
the  left  side  there  was  a  feeling  as  if  something  in  the  abdomen  was 
drawing  from  right  to  left. 

In  December,  1901,  a  hard  swelling  was  found  in  the  epigastrium. 
No  vomiting,  but  frequent  sour  eructation;  feeling  of  fulness  in  the 
stomach.  Decrease  in  weight  (November,  1901,  to  February,  1902) 
10  kg. 

ad  7.- — Subicteric  discoloration ;  on  the  right  side,  underneath  the 
costal  arch,  a  tumor-mass  which  is  hard,  possessing  very  distinct  respira- 
tory mobility,  over  the  tumor  an  empty  sound  on  percussion.  In  this 
locality  also  pain  on  deep  breathing  and  tenderness  on  pressure.  Stom- 
ach not  dilated.     No  edemas. 

Stomach  contents:  After  test-breakfast  1%  HCl;  bacteriological  find- 
ings negative. 

Urine:  Urobilinogen  positive ;  traces  of  bilirubin. 

ad  8. — Beginning:  Early  in  November,  1901. 
Status  presens :  February  28,  1902. 
Operation:  March  16,  1902. 
ad  9. — Finding  at  operation  (Clinic  of  late  Hofrat  Professor  Dr. 
A'.   Gussenbauers,   Professor   Dr.   0.   Foederl)  :   Carcinoma   of   the   gall- 
bladder, encroaching  on  the  left  lobe  of  the  liver.     Pylorus  drawn  up- 
ward. 

Epicrisis:  This  case  ran  its  course  entirely  under  the  aspect  of  a 
gastric  disease.      The   stomach   cramps   existing   for  a   numlx>r   of  years 


320  TUMORS    OF    THE    ABDOMINAL    VISCERA 

and  related  to  food  intake,  as  referred  to  in  the  history,  suggested  a 
gastric  ulcer.  But  also  the  symptoms  occurring  since  November,  1901, 
lead  one  to  think  in  the  first  place  of  a  disease  located  at  the  pylorus. 
The  pain  appeared  mostly  two  hours  after  eating,  hence  coincided  with 
the  expulsion  period  of  the  stomach  and  became  increased  with  right 
lateral  position,  etc. 

Laparotomy  also  actually  disclosed  a  lesion  in  the  region  of  the 
pylorus  but  only  in  the  form  of  a  displacement  upward  toward  the 
carcinomatously  diseased  gall-bladder,  which  could,  indeed,  give  rise  to 
kinking  and  constriction.  The  urine  contained  traces  of  bilirubin.  This 
case,  therefore,  belongs  to  the  gastric  types  ^~  of  carcinoma  of  the 
gall-bladder. 

Case  19. — F.  R.,  57  years,  M.    Street  cleaner. 

ad  3. — No  infectious  diseases  during  childhood,  was  always  healthy, 
ad  4. — Appetite   always  good,   could   tolerate   all  kinds   of   foods; 
bowels  always  regular. 

ad  5.— Two  years  ago  (1901)  while  doing  heavy  work  had  pain 
on  and  off  on  the  right  side  underneath  the  costal  arch,  lasting  only  two 
to  three  days  at  a  time. 

ad  6. — In  January,  1903,  there  began  slight  stabbing  pain  under- 
neath the  right  costal  arch. 

In  February,  1903,  this  pain  became  severer,  the  bowels  becoming 
irregular. 

The  patient  followed  his  work  until  March  9,  1903.  The  appetite 
remained  good  but  the  patient  dared  not  eat  nmch  because  it  produced 
a  feeling  of  pressure.  The  above-mentioned  pain  appeared  especially  when 
sitting.  Left  lateral  position  is  badly  tolerated  because  it  produces  a 
feeling  as  if  something  in  the  alxiomcn  was  drawing  from  right  to  left, 
ad  7. — Jaundice  (appearing  ]March  24,  then  increasing  rapidly). 
Resistance  underneath  the  right  costal  arch,  the  liver  there  being  of  a 
bony  hardness,  somewhat  uneven  on  the  surface.  Peritoneal  friction 
can  be  heard  in  the  region  of  the  gall-bladder,  also  constant  squirting 
sounds.     No  ascites,  no  edema.     Afebrile  course. 

Stomach  contents:  HCl   negative  after  test-breakfast. 
Urine:  Abundant  urobilinogen,  later  also  bilirubin.     Toward  the  end 
there  was  ascites. 

ad  8. — Beginning:  January,  1903. 

Status  presens :  March  26,  1903. 
Autopsy:  May  9,  1903. 
Duration :   About  4  months, 
ad  9. — Autopsy  (Professor  Dr.  A.  Ghon^  :  Scirrhus  carcinoma  of 
the  gall-bladder,  invading  the  liver  and  the  transverse  colon  with  per- 
foration   into    the   latter.      Secondary    carcinoma    of   the   liver   and    the 
lymph-nodes  at  the  hilum.     Biliary  calculi  in  the  neck  of  the  bladder, 


'^  See  Case  11. 


CARCINOMA    OF    THE    GALL-BLADDKK  IV2\ 

in  tlic  cystic  duct  and  in  the  ductus  choledochus.    Severe  icterus.    Chronic 
tumor  of  the  spleen.     General  hydrops.     Chronic  apical  tul)erculosis. 

Epicrisis:  Peritoneal  friction  in  the  region  of  the  gall-i)ladder !  In 
the  same  place  there  also  existed  pain,  which  appeared  especially  when 
sitting  down.  Distinct  icterus  first  occurred  six  weeks  before  death, 
and  then  was  rapidl}'  progressive.  It  was  ushered  in  by  abundant  elimi- 
nation of  urobilinogen.     Toward  the  end  ascites  also  set  in. 

Case  20.— N.  N.,  70  years,  F.    Farmer's  wife. 

ad   1. — Husband  died  of  gastric  cancer. 

ad  2. — During  the  past  few  years  she  has  had  frequent  rheumatic 
pain  in  the  finger-joints. 

ad  4. — Now  and  then  suffers  from  stomach  cramps  for  a  short 
time  after  copious  drinking  of  water. 

ad  6. — In  the  beginning  of  February,  1908,  appearance  of  stab- 
bing pain  in  the  axillary  line  over  the  liver,  on  deep  breathing.  Hot 
compresses  relieved  this  pain.  Since  then  there  is  present  anorexia. 
The  patient  eats  only  soup. 

ad  7. — Subicteric  discoloration  with  severe  itching  of  the  skin. 
The  gall-bladder  can  be  felt  as  a  very  firm  tumor;  above  it  the  adjacent 
liver-tissue  is  infiltrated  and  hard  as  a  board. 

ad  8. — Beginning:  Early  part  of  February,  1908. 
Status  prescns:  March  13,  1908. 
Death:  A  short  time  after. 
Epicrisis:  There  were  indications  of  dyscrasia,  such  as  chronic  pain 
in  the  finger-joints,  recurring  repeatedly  during  the  past  years.     Pains 
in  the  axillary  region  of  the  liver  occurring  with  deep  respiration,  are 
mentioned  as  initial  symptoms. 

The  gall-bladder  can  be  distinctly  felt  as  a  tumor,  the  seat  of 
metastases  being  in  the  immediately  adjacent  portions  of  the  liver- 
tissue. 

Case  21.— R.  E.,  67  years,  M. 

ad  3. — At  24  had  malaria  for  two  years. 

ad  4. — Never  had  any  gastro-intestinal  disturbances. 

ad  6. — The  disease  began  in  August,  1897,  with  pressing  pain 
in  the  right  flank  just  underneath  the  costal  arch,  especially  when  sitting; 
when  walking  or  lying  down  there  were  no  complaints.  Jaundice  being 
of  varying  intensity  in  the  beginning.  After  ingestion  of  food  there  was 
a  feeling  of  distention;  since  November,  1907,  disgust  toward  meat  and 
fat ;  desire  for  sour  and  sweet  foods.  Since  then  remarkable  dryness  of 
the  tongue.     Severe  emaciation  since  the  beginning  of  the  disease. 

ad  7. — The  left  half  of  the  tongue  shows  an  atrophic  mucous  mem- 
brane. Liver  diffusely  much  enlarged,  of  moderately  firm  consistence. 
The  gall-bladder  is  palpable.     Bigeminal  pulse. 

Afebrile  course.  Toward  the  end  severe  edema  around  the  ankles 
(coming  on  suddenly  after  a  warm  foot  bath);  likewise  great  ascites 
and  hvdrothorax.     Afebrile  course.     Death  with  mild  hematemesis. 


322  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  8. — Beginning:  August,  1897. 

Status  prcsens  :  January  7,  1898. 
Autopsy:  March,  1898. 
Duration :  About  8  months. 
Ad  9. — Autopsy:  ^'illiform  cancer  of  the  gall-bladder  (gall-bladder 
much  enlarged  and  tense)  ;  carcinomatous  masses   in   the  ductus  chole- 
dochus  and  at  the  outlet  of  the  cystic  duct.     No  appreciable  metastasis 
in  the  liver;  enlargement  due  to  biliary  congestion.   Blood  in  the  stomach 
and  duodenum  from  a  ruptured  vein  in  the  esophagus. 

Epicrisis:  The  initial  pains,  occurring  like  those  in  Case  20  when 
in  the  sitting  position,  are  very  probably  referable  to  disease  in  the  gall- 
bladder itself,  the  location  of  which  corresponds  to  the  place  of  the 
pain.  The  pressure  exerted  on  the  gall-bladder  in  the  sitting  position 
may,  w^th  a  sensitive  organ,  be  looked  upon  as  a  pain-provoking  factor. 
The  jaundice  in  the  beginning  showed  a  variation  in  intensity,  which, 
however,  was  later  followed  by  a  constant  progressiveness.  During  the 
last  months  there  was  present  meat  anorexia  with  a  preference  for  sweet 
and  sour  foods.  The  atrophic  conditions  of  the  lingual  mucosa  arc 
worthy  of  note.  They  have  been  noticed  repeatedly  with  other  forms  of 
visceral  cancer. 

The  enlargement  of  the  liver  was  dependent  solely  upon  biliary  con- 
gestion, and  accordingly  the  consistence  was  only  moderately  increased. 
The  terminal  hematemesis  was  due  to  a  ruptured  varix  of  the  esopha- 
gus.    Latent  edemas  in  connection  with  cachectic  processes  may  make 
their  appearance  after  hot  foot-baths. 

Case  22.— A.  S.,  73  years,  M. 

ad  2. — Since  1884  there  have  been  repeated  attacks  of  articular 
rheumatism  involving  many  joints,  including  the  finger- joints,  and  ap- 
pearing mostly  in  the  spring  of  the  year;  for  the  past  three  years  the 
attacks  have  diminished  in  intensity. 

ad  3. — Appetite  and  bowels  always  regulated,  except  that  dur- 
ing the  past  four  years  without  any  dietetic  error  there  has  appeared 
on  and  off  a  feeling  of  epigastric  pressure  and  eructation;  during  this 
time  the  patient  vomited  only  four  times ;  after  vomiting  the  complaints 
usually  ceased  for  a  rather  long  time.  For  the  past  four  or  five  years 
there  exists  intolerance  toward  fat  foods, 

ad  5. — The  use  of  alcohol  is  admitted  (5  litres  beer  daily). 

ad  6. — Was  taken  sick  early  in  the  morning  of  October  29,  1904< ; 
chill,  pain  over  the  lower  part  of  the  sternum  and  to  the  right  of  it, 
accompanied  by  nausea  and  bitter  eructation ;  breathing  caused  pani  an- 
teriorly on  the  right  side  of  the  thorax,  and  also  between  the  shoulder- 
blades  ;  stabbing  in  the  region  of  the  heart.-  On  the  folloAving  day  re- 
peated chill,  followed  by  a  feeling  of  heat.  About  November  5,  1904, 
the  stools  became  light  in  color,  the  urine  dark  red.  Of  late  (entered 
hospital  November  26,  1904)  feeling  of  exhaustion  and  insomnia. 
Anorexia.     jNIoderate  loss  of  weight. 

ad  7. — Icterus  of  mediinii  degree,   subsequently  increasing.    Liver 


CARCINOMA    OF    THE    GALL-liLADDKR  ;j23 

slightly  enlarged,  also  the  spleen.  Gnll-blatlder  enlarged,  walls  soft, 
tender  on  pressure.  Pulse  52.  Afebrile  course.  \  ery  slight  edema  of 
the  legs. 

Urine:  Diazo  reaction  negative  in  the  beginning,  later  constantly 
positive. 

Blood:  0,800  leucocytes. 

December  14,  190-i:  Severe  hematemesis ;  ten  bowel  evacuations,  con- 
sisting of  blood,  containing  only  a  few  preserved  erythrocytes, 
ad  8.— Beginning:  October  29,  1904. 

Status  presens :  November  26,  1904. 

Autopsy:  December  16,  1904.  , 

Duration:  IY2  months, 
ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Carcinoma  of  the  termi- 
nal portion  of  the  ductus  choledochus,  proliferating  into  the  duodenum; 
at  the  latter  place  ulceration  above  the  papilla  of  Vater  and  hcmorriiage 
from  a  branch  of  the  pancreatic-duodenal  artery.  Fresh  blood  in  the 
small  and  large  intestine.  Very  small  metastases  in  the  liver.  Chronic 
tumor  of  the  spleen.  Great  dilatation  of  the  gall-bladder  and  the 
ductus  choledochus.  Small  calculi  in  the  gall-bladder.  Chronic  en- 
darteritis deformans,  especially  in  the  periphery. 

Epicrisis:  Recurring  articular  rheumatism,  probably  in  the  nature  of 
a  dyscrasia !  The  clinical  beginning  of  the  disease  is  acute  (October  29), 
with  pain  and  chill,  with  manifestations  of  a  gall-stone  colic ;  several  days 
later,  icterus.  It  may  be  assumed  w^ith  the  greatest  probability  that 
the  flow  of  bile  was  halted  at  that  time,  and  this,  together  with  the 
presence  of  concretions,  led  to  a  sort  of  "constriction  colic"  of  the  biliary 
passages. 

Changes  in  the  wall  of  the  gall-bladder  were  not  demonstrable  by 
palpation. 

Diazo  reaction  was  absent  in  the  beginning  but  later  was  constantly 
positive  (cholangitic  infection?). 

Despite  existing  indications  of  a  general  hemorrhagic  diathesis  (cuta- 
neous hemorrhage!  epistaxis!)  the  terminal  hemorrhage  was  correctly 
interpreted  as  an  erosion  hemorrhage,  high  up.  Its  situation  high  up  was 
indicated  by  the  almost  entirely  negative  finding  of  preserved  cells  of 
the  blood;  at  the  same  time  this  finding  I'uled  out  diffuse  parenchymatous 
bleeding  from  the  intestinal  mucosa.  The  enormous  quantity  of  the 
hemorrhage  pointed  to  an  erosion  of  one  of  the  larger  blood-vessels. 

Case  23.— M.  T.,  52  years,  M. 

ad  1.- — Longevity  of  both  parents. 

ad  3. — Typhoid  at  4  3'ears  of  age;  in  1873  was  sick  with  pneu- 
monia for  9  weeks. 

ad   4. — Appetite  always  good,  bowels  regular. 

ad   5. — As  a  child  was  strong,  and  also  otherwise  well. 

ad  6. — On  May  3,  1903,  the  patient  had  jaundice,  same  lasting 
about    three    months,    i.e.,    up    to    the   beginning    of    August,    1903,    but 


324  TUMORS    OF    THE    ABDOINIINAL    MSCERA 

without  pain  and  without  an\^  gastro-intestinal  symptoms;  only  now  and 
then  there  was  a  feeling  of  heat  and  cold. 

At  the  end  of  July,  1904,  the  patient  felt  perfectly  well,  except  that 
on  and  off  there  were  night-sweats,  so  much  so  that  it  was  necessary  to 
change  shirts. 

About  one  year  later,  in  September,  1904,  after  eating  "goulash," 
nausea  and  vomiting  came  on  during  the  night,  without  pain ;  four  days 
later  the  sclera?  became  yellow  and  increasing  jaundice  appeai'ed. 

On  November  28,  1904,  there  was  general  good  laalth,  so  that  the 
patient  left  the  clinic. 

On  December  14,  1904, "in  the  evening  there  appeared  sudden  ex- 
tremely intense  headache,  accompanied  by  nose-bleed.  At  the  same 
time  fever  set  in,  reaching  38°  C.  in  the  evening  hours.  Painless  course, 
ad  7. — November  4,  1904:  Icterus  of  medium  degree.  The  right 
hepatic  lobe  extends  somewhat  farther  downward  and  feels  somewhat 
more  resistant.  The  gall-bladder  is  not  palpable.  The  spleen  is  slightly 
enlarged,  soft.     Pulse  50 ;  no  edemas,  no  fever. 

Urine:  Abundant  urobilinogen;  indican  reaction  positive;  no  alimen- 
tary glycosuria. 

Feces:  Urobiltnogen  positive. 

Stomach  contents:  After  test-breakfast  total  acidity  64V',  1-10  N. 
NaOH.     No  hcmcralopia. 

December  24,  1904:  Status  fcbriles;  tongue  very  dry.  Pulse  90, 
dicrotic,  great  tachypnea.     Perihepatic  friction.     No  edema. 

Blood:  14,000  leucocytes,  increasing  up  to  20,000. 

Toward  the  end,  epistaxis,  thinly  fluid  sanguineous  stools,  hema- 
temesis;  severe  chills. 

ad  8. — Beginning:  May,  1903. 
^  Status  presens:  November  4,  1904,  and  December  24,  1904. 

Autopsy :  December  29,  1904. 
ad  9. — Autopsy  (Dr.  R.  t*.  Wiesner)  :  Carcinoma  of  the  papilla 
Vateri  with  stenosis  and  congestion  of  the  eliminating  bile  channels. 
Multiple  cholangitic  abscesses  with  adhesions  between  the  surface  of  the 
liver  and  the  diaphragm.  Fresh  fibrinous  pericarditis.  Icterus  gravis 
with  hemorrhagic  diathesis.     Subacute  splenic  tumor. 

Bacteriological  finding  in  the  pus  from  abscesses ;  staphylococcus 
pyogenes. 

Epicrisis:  Worthy  of  note  is  the  course  of  the  icterus,  coming  and 
going  three  different  times. 

First  period:  May  3,  1903,  to  August,  1903. 

Second  period:  September,  1904,  to  November,  1904. 

Third  period:   November,   1904,  to  December,   1904. 

This  behavior,  in  connection  with  the  febrile  course,  must  have  sug- 
gested, in  the  first  place,  a  recurring  cholangitic  process.  Without 
doubt  such  a  complication  was  also  present  and  accounted  for  the 
great  variations  in  the  course  of  the  disease.  The  pus  taken  from  the 
cholangitic  abscesses  after  death  showed  staphylococci.  Accordingly 
during  life  there  was  a  high  Icucocytosis   (up  to  20,000)   and  diazo  re- 


CARCINOMA    OF    THE    GALL-BLADDER  325 

action  was  absent."'"'  The  infection  may  have  conic  from  the  ulcerating 
carcinoma  at  the  {)apilla  of  ^'ater  and  at  any  rate  was  favored  by  the 
biliary  congestion  produced  by  the  carcinoma.  The  existing  cholangitis 
during  the  later  course  led  to  an  objectively  demonstrable  perihepatitis. 
During  the  last  stage  of  the  disease  there  was  complete  biliary  occlusion 
(no  urobilinogen  in  the  stool).     Gall-bladder  large,  soft. 

The  absolutely  painless  course  of  the  disease,  as  compared  to  the 
usual  behavior  in  cancer  of  the  gall-bladder,  is  worthy  of  attention. 

In  and  of  themselves  such  cases,  at  least  in  their  initial  stages,  could 
easily  be  mistaken  for  catarrhal  jaundice.  Experience  teaches,  how- 
ever, that  after  the  fiftieth  year  of  life  catarrhal  jaundice  counts  among 
the  greatest  rarities. 

Case  24. — F.  J.,  59  years,  M.    Letter  carrier. 

ad  3. — Measles  at  10;  at  28  had  tonsillitis  for  eight  weeks;  in 
March,  1905,  had  a  left-sided  pneumonia  for  four  weeks, 
ad  4. — Appetite  always  good,  bowels  regular, 
ad  6. — In  the  beginning  of  June,  1905,  the  patient  began  to  feel 
bad:  Exhaustion,  anorexia  and  disgust  toward  meat,  sour  eructation 
after  larger  meals,  headache  and  mild  jaundice.  On  June  10,  the  patient 
had  to  take  to  his  bed.  The  jaundice  increased.  Bowels  moved  daily. 
No  kind  of  pain.     In  the  beginning  of  July,  1905,  had  chills. 

ad  7. — Severe  jaundice.  Moderate  enlargement  of  the  liver,  con- 
sistence not  appreciably  increased.  On  palpating  from  above  down- 
ward the  gall-bladder  can  be  felt ;  its  walls  are  soft,  little  tender  to 
pressure.  The  spleen  extends  almost  to  the  costal  arch,  is  soft.  Numerous 
angiomatous  formations.  Temperature  elevations  up  to  39.6°  C.  Very 
severe  retromalleolar  edema. 

Urine:  Indican  reaction  strongly  positive;  no  aldehyde  reaction. 
Feces:  Many  neutral  fat  globules;  in  the  fat  globules  there  is  blood 
pigment !     Blood-coloring  material  is  chemically  demonstrable, 
ad  8. — Beginning:  Early  in  June,  1905. 
Status  presens:  July  15,  1905. 
Autops}' :  August  5,  1905. 
Duration :  About  2  months, 
ad  9. — Autopsy  (Professor  Dr.  A.  Ghoji)  :  Medullary  tumor  about 
the  size  of  a  nut,  at  the  papilla  of  Vater  with  compression  of  the  ductus 
choledochus   and  pancreaticus ;   dilatation    of  the   latter   as   well   as   the 
hepatic  duct  and  its  branches  in  the  liver.     ^Multiple  abscesses  in  the  liver 
and  general  icterus  of  high  degree.     Multiple  fat  necrosis  of  the  pancreas. 
General  obesity  and  fatty  heart. 

Histological  cxomination:  Papillary  carcinoma. 

Epicrisis:  It  is  possible  that  ulcerating  cancers  at  the  papilla  of 
Vater  frequently  lead  to  an  ascending  infection  of  the  bile-ducts  from  the 
ulcerating  surface.  In  this  case  also  the  body  temperature  occasionally 
rose  to  39.6°  C,  autopsy  disclosing  small  cholangitic  abscesses.     When 

''  According  to  my  observntion,  general  staphvlococcvis  infections,  in  contradistinc- 
tion to  streptococcus  infections,  are  not,  as  a  rule,  accompanied  by  a  diazo  reaction. 


326  TUMORS    OP^    THE    ABDOMINAL    VISCERA 

the  ditferential  diagnosis  wavers  between  cancer  of  the  head  of  the 
pancreas  and  cancer  of  the  papilla  of  ^'ater  it  seems  to  me  that  a  high 
febrile  course  favors  the  latter  diagnosis. 

Fat  intolerance,  met  with  in  the  histories  of  a  large  percentage  of 
cases  of  cholelithiasis,  was  not  found  in  this  case ;  neither  was  there  the 
frequently  accompanying  symptom  of  constipation.  Besides  this  the  wall 
of  the  gall-bladder  could  be  felt  and  was  soft. 

The  early  appearance  of  jaundice  argued  against  a  gastric  cancer 
despite  the  existing  meat  anorexia ;  furthennore,  the  vegetations  in  the 
feces  consisted  almost  exclusively  of  Gram-negative  rod-shapes,  lactic- 
acid  bacilli,  therefore,  being  absent.  Despite  stenosis  of  the  pancreatic 
duct  (autopsy  showed  great  dilatation)  the  formation  of  indol  in  the 
intestinal  canal  was  rather  increased  and  the  urine  yielded  a  strongly 
positive  indican  reaction. 

The  existence  of  a  macroscopicall}-  occult  melena  could  be  shown  under 
the  microscope,  in  so  far  as  the  neutral  fat  globules  in  the  stool  were 
filled  with  amorphous  Ijrown  blood  pigment. 

Case  25.— N.  N.,  73  years,  M. 

ad  6.- — Since  about  April  24,  1908,  continuous  })ain  in  the  epigas- 
trium, anorexia  and  constipation.  No  eructation,  no  vomiting.  Emacia- 
tion. There  is  a  feeling  as  if  solid  foods  were  caught  at  about  the  height 
of  the  manubrium  of  the  sternum. 

ad  7. — No  jaundice.  Tongue  nmch  indented.  Liver  greatly  en- 
larged, moderately  firm;  perihepatic  friction.  Only  near  the  end  was  there 
"coft'ee-ground"  vomiting,  in  which  HC'l  was  clearlv  positive.  Repeated 
chills  (up  to  39.9°  C). 

Stomach  contents:  Desmoid  reaction  positive  after  five  hours. 
Feces:  Chemical  blood-test  constantly  positive. 
Blood:  4,300  to  9,960  leucocytes. 

ad  8.— Beginning:  About  April  24,  1908. 
Status  presens:  May  8,  1908. 
Autopsy:  May  29,  1908. 
ad  9. — Autopsy   (Pros.   Professor  Dr.  Fr.  Schlangenhaufer)  :  ul- 
cerating carcinoma  of  the  duodenum  (old  ulcer  base.'*)  with  efosion  of  one 
of  the  larger  blood-vessels   and   suppurative   phlebitis.     Phlebitic   metas- 
tases in  a  branch  of  the  portal  vein  and  secondary  putrefaction  of  several 
cancerous  nodules,  numerous   cancerous  metastases  in   the  liver.    Slight 
adhesion  of  the  stomach  to  the  liver. 

Epicrisis:  As  in  Cases  24  and  25,  so  also  here,  the  carcinomatous 
proliferation  in  the  duodenum  runs  its  course  accompanied  by  high  tem- 
peratures (39.9°  C.)  and  chills.  Autopsy  reveals  putrid  abscesses  in  the 
liver.  At  times  there  was  leucopenia  (5»000,  4,300),  only  near  the  end  the 
leucocyte  count  was  somewhat  increased  (9,900).  The  accompanying  peri- 
hepatitis pointed  to  the  infectious  process  in  the  liver.  Jaundice  was  absent. 
Blood-coloring  matter  was  constantly  chemically  demonstrable  in  the 
feces.  The  stomach  contents  vomited  toward  the  end  distinctly  showed 
free  HCl. 


Carcinoma  of  the  Pancreas 


Case  1. — M.  C,  64  years,  M. 

ad  6. — Since  the  beginning  of  January,  1900,  there  lias  been  ano- 
rexia. On  January  16,  1900,  there  occurred  sudden  pains,  not  cramp-like, 
in  the  right  axillary  line,  corresponding  to  the  costal  arch,  radiating 
into  the  right  side  of  the  abdomen.  They  lasted  three  weeks,  bore  no  rela- 
tion to  intake  of  food  and  became  exacerbated  at  night.  No  febrile  move- 
ments. Later,  pain  came  on  half  an  hour  after  eating,  and  this  pain  let 
up  somewhat  when  the  patient  maintained  a  partly  stooping  position. 
Often  odorless  eructation,  seventeen  to  eighteen  times  in  succession.  Since 
about  Ma}^  20,  1900,  icterus  is  present,  which  now  (June,  1900)  is  in- 
tense. No  vomiting;  no  nausea.  Appetite  is  slight.  No  pain  in  the  back; 
the  epigastrium  tender  on  pressure. 

ad  7. — Great  emaciation;  jaundice.  Epigastrium  bulging,  tense, 
like  an  air-cushion,  liver  slightly  enlarged ;  on  the  right  side,  underneath 
the  costal  arch,  pea-size  nodules  can  be  felt  on  the  surface  of  the  liver 
when  the  patient  is  lying  on  his  right  side,  the  same  on  the  left.  Gall- 
bladder enlarged.    Retromalleolar  edema,  later  on  ascites. 

Toward  the  end  "coffee-ground"  vomiting  with  few  lactic-acid  bacilli. 

ad  8. — Beginning:  Early  in  January,  1900. 
Status  presens :  June  5,  1900. 
Autopsy:  June  24,  1900. 
Duration:  About  six  months. 

ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Scirrhus  cancer  of  the 
tail  of  the  pancreas,  invading  the  posterior  wall  of  the  pyloric  portion  of 
the  stomach  and  uppermost  portion  of  the  duodenum,  perforating  both. 
Constriction  of  the  pylorus  and  the  ductus  choledochus  immediatelj  below 
the  outlet  of  the  cystic  duct.  Icterus  gravis.  Secondary  scirrhus  cancer 
of  the  liver  and  the  large  omentum,  with  contraction  of  same,  of  the 
retroperitoneal  and  mesenteric  lymph-nodes  and  the  peritoneum.  Invasion 
and  perforation  of  isolated  cancer  nodules  of  the  mesentery  in  the  small 
and  large  intestine,  with  the  formation  of  ulcers.  Hemorrhagic  peri- 
tonitis. 

Epicrisis:  On  the  one  hand  there  was  jaundice  and  enlargement  of  the 
gall-bladder ;  on  the  other  hand  there  was  the  stomach  distended  like  an 
air-cushion  and  frequent  successive  eructations. 

Coincident  congestion  of  bile  and  stagnation  of  stomach  contents,  to- 
gether with  cancerous  cachexia,  would  always  make  us  think  of  a  possible 

carcinoma  of  the  pancreas. 

337 


328  TUMORS    OF    THE    ABDOMINAL    VISCERA 

The  pain  in  the  axillary  line  appearing  quite  early  may  have  been  due 
to  metastases  in  the  liver  or  to  distention  of  the  gall-bladder.  Pain  in  the 
back  was  absent. 

There  was  a  diffuse  carcinomatosis  of  the  peritoneum  with  shrivelling 
of  the  mesentery,  which  led  to  intestinal  ulcers ;  the  tumor-mass  showing 
small  nodules,  which  could  be  felt  underneath  the  costal  arch,  belonging  to 
the  omentum  which  was  the  seat  of  carcinomatous  infiltration. 

Case  2.— M.  K.,  36  years,  F. 

ad  2. — Since  her  20th  j^ear  has  had  headache  three  to  four  times  a 
month,  appearing  especially  toward  evening  and  followed  by  a  feeling  of 
weakness  the  next  day. 

ad  3. — As  a  child  had  measles. 

ad  5. — In  December,  1899,  sudden  pain  in  both  wrist-joints,  several 
days  later  swelling  in  the  joint  of  the  left  thumb,  together  with  redness 
and  a  feeling  of  heat.    No  fever. 

Duration  of  the  illness :  one  month. 

In  January,  1900,  painful  swelling  in  both  knee-joints.  Duration: 
several  days. 

ad  6. — In  February,  1900,  there  began  particularly  severe  pain  in 
the  back,  lasting  until  the  present  time  (November,  1900);  besides  also 
pain  in  the  hips. 

In  June,  1900,  the  patient  began  to  emaciate  (at  present,  in  Novem- 
ber, 1900,  weighs  -10  kg;  two  years  ago,  08  kg).  The  pain  in  the  back 
constantly  increased. 

In  September,  1900,  occurrence  of  icterus. 

Stomach  complaints  began  in  October,  1900.  Feeling  of  fulness  after 
eating,  vomiting  of  mucus,  eructation.  Bowel  movements  remained  reg- 
ular. There  are  pains  in  the  back  which  become  exacerbated  when  lying 
on  the  belly,  are  somewhat  relieved  when  lying  on  the  right  side,  and  also 
relieved  by  defecation  and  discharge  of  gases.  Anteriorly  in  the  region 
of  the  umbilicus  now  and  then  colicky  pain,  and  when  these  come  pn  the 
pain  in  the  back  becomes  worse. 

ad  7. — A  greatly  emaciated,  jaundiced  patient;  gall-bladder  en- 
larged and  visibly  protuberant.  Dilated  stomach  extending  to  the  level  of 
the  umbilicus,  splashing. 

Stomach  contents:  HC'l  positive,  many  sarcina?.  A  hard,  uneven  tumor- 
mass  can  be  felt  in  the.  epigastrium  deep  between  recti  muscles  which  have 
become  separated ;  the  tumor  is  not  movable.  Anterior  to  it  and  resting 
upon  it,  a  round  contracted  cord,  as  thick  as  a  finger,  can  be  felt,  which 
after  a  short  time,  accompanied  by  a  squirting  sound,  gives  up  its  con- 
traction and  becomes  soft  (contractions  of  the  p3'lorus!).  In  the  epigas- 
trium also  a  systolic  murmur  is  audible  when  the  ear  or  stethoscope  is 
gently  and  without  pressure  placed  against  the  belly-wall.  Strong  aortic 
pulsation  in  the  epigastrium.  Tenderness  to  pressure  over  the  sacrum,  the 
left  crest  of  the  ilium,  the  left  trochanter  and  also  the  vertebral  column, 
from  the  second  lumbar  vertebra  downward ;  the  left  thigh  is  held  flexed, 
extension  of  the  left  leg  is  painful.    The  pains  in  the  back  persist  despite 


CARCINOMA  OF  THE  PANCREAS         329 

2.0  g  pyramidon  per  day.    The  spleen  is  not  palpable.    Profuse  bleeding 
from  a  small  scratcli  wound  in  the  right  cubita. 

Urine:  Indican  reaction  negative;  no  glycosuria.    Afebrile  course, 
ad  8. — Beginning:  February,  1900. 

Status  presens:  November  21,  1900. 
Autopsy^^ :  January  27,  1901. 
Duration:  About  1  year, 
ad  9. — Autopsy:  Scirrhus  of  the  pancreas,  proliferating  into  the 
ductus  choledochus.    Adhesions  to  the  abdominal  aorta  and  narrowing  of 
same.   Metastases  in  the  left  pleura,  in  the  left  lung,  left  suprarenal  body. 
Ascites,  anasarca. 

Epicrisis:  About  three  months  prior  to  the  appearance  of  the  first 
symptom  (pain  in  the  back)  of  cancer  of  the  pancreas  there  had  de- 
veloped in  this  36-year-old  patient  an  afebrile  articular  rheumatism 
(dyscrasia.'^). 

This  order  of  succession  is  not  altogether  too  rare,  and  probably 
justifies  the  question  whether  "internal  traumas"  in  the  nature  of  a 
dyscrasia  are  not  capable  of  giving  to  cells,  predisposed  that  way,  the 
impulse  to  cancerous  proliferation. 

It  is  highly  probable  the  pains  in  the  back  appearing  early  in  Febru- 
ar}',  1900,  were  misinterpreted  as  "rheumatic" ;  as  late  as  June  and 
July,  1900,  they  were  treated,  naturally  without  results,  by  means  of  mud 
baths.  These  pains,  probably  to  a  great  extent,  were  dependent  on  the 
retroperitoneal  tumor-mass,  and  later  also  influenced  by  the  dilated  stom- 
ach (relief  after  defecation,  discharge  of  flatus!).  The  inefficacy  of  an- 
tineuralgics  (2  g  p3'ramidon  per  day)  is  worthy  of  note  and  occasionally 
of  diagnostic  value. 

Analogous  to  Case  1,  we  have  also  here  coincident  stagnation  of  bile 
and  stomach  contents,  the  former  shown  by  the  icterus,  the  latter  by  the 
gastric  dilatation  and  presence  of  sarcinjE.  HCl  persists  and  is  explained 
by  the  fact  that  pyloric  constrictions  produced  by  malignant  processes 
from  without  (cancer  of  the  pancreas  and  gall-bladder)  usualh'  run  along 
with  the  symptoms  of  a  benign  stenosis  (persistence  of  HCl  and  sarcinte). 

Retroperitoneal  tumors  in  the  epigastrium  not  seldom  account  for  the 
fact  that  the  pyloric  portion  of  the  stomach  is  displaced  forward,  so  that 
in  its  resting  state  and  particular!}'  when  in  a  contractile  state  it  becomes 
distinctly  palpable.  In  this  case  the  pj'lorus  could  at  one  time  be  felt  as 
a  soft  cord  and  at  another  as  a  round,  tense  cord,  similarly  as  in  func- 
tional "peristaltic  unrest." 

The  systolic  vascular  murmur  in  the  epigastrium  owed  its  existence  to 
a  compression  of  the  abdominal  aorta,  as  shown  at  autopsy.  Such  con- 
strictions of  moderate  degree  are  usually  compensated  so  that  there  re- 
sults no  anomaly  of  the  crural  pulse. 

The  urine  yielded  no  positive  indican  reaction,  a  finding  for  that 
matter  which  in  and  of  itself  carries  with  it  no  special  significance. 

^Performed  in  the  Prosektiir  des  K.  K.  Garnisonsspitales,  No.  1,  Vienna. 


330  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  3. — J.  S.,  40  years,  M.    Innkeeper. 

ad  1. — Mother  died  of  a  pulmonary  disease. 

ad  3. — Had  no  febrile  disease  in  childhood ;  at  22  had  erysipelas. 

ad  5, — Alcohol  to  excess. 

ad  6. — In  the  beginning  of  November,  1901,  there  came  on  a  con- 
tinued feeling  of  pressure,  at  first  underneath  the  xiphoid  process,  later 
radiating  to  the  right,  along  the  costal  arch,  and  subsequently  localized 
particularly  in  the  region  of  the  gall-bladder.  At  night  the  patient  lay  on 
his  right  side  with  the  arm  under  him  so  as  to  protect  the  painful  region 
of  the  gall-bladder  from  pressure.  When  U'ing  on  the  left  side  there  was 
a  feeling  of  pulling  toward  the  left.  At  the  start  there  were  chills  now  and 
then  at  night  together  with  breaking  out  of  a  cold  sweat.  No  vomiting; 
good  appetite  until  the  end  of  January,  1902;  half  an  hour  after  drink- 
ing milk  there  was  a  feeling  of  distention  in  the  belly.  Jaundice  present 
since  the  middle  of  December,  1901.    No  pain  in  the  back. 

ad  7. — A  greatly  emaciated  cachectic  individual;  jaundice.  Epi- 
gastrium distended.  Liver  hard,  enlarged  downward  about  the  width  of 
one  hand,  with  a  protuberance  as  big  as  a  cherry,  in  the  middle  line.  Gall- 
bladder is  large,  its  long  axis  opposed  obliquely  to  the  iicpatic  border, 
distinctly  palpable.  Spleen  slightly  enlarged,  extending  to  the  costal  arch. 
Severe  retromallcolar  edema ;  scratches  inclined  to  bleed  easily.  No 
bradycardia. 

Toward  the  end  moderate  melena,  the  bowel  evacuations  consisting 
partly  of  red  blood  and  partly  of  hard  clots.  Pneumonia  and  pericarditis 
as  terminal  complications. 

Vomited  stomach  contents:  Isolated  lactic-acid  bacilli. 

ad   8. — Beginning:  Early  in  November,  1901. 
Status  presens:  January  29,  1902. 
Autopsy:  February  10,'  1902. 
Duration:  About  3  months. 

ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Carcinoma  of  the  head 
of  the  pancreas,  projecting  into  the  duodenum  ;  compression  of  the  ductus 
choledochus  and  the  duct  of  Wirsung  in  their  lowermost  portions.  Severe 
icterus.  Splenic  tumor.  Several  small  cancer  nodules  in  the  liver.  Bilat- 
eral encapsulated  apical  tuberculosis.  Adenomatous  nodules  in  the  right 
lobe  of  the  thyroid  gland.    Arteriosclerosis  of  the  coronary  arteries. 

Epicrisis:  This  40-3'ear-old  patient  had  had  no  infectious  diseases 
during  childhood,  a  statement  made  by  surprisingly  many  cancer  patients 
under  my  observation. 

This  patient's  illness  began  with  a  feeling  of  epigastrium  pressure 
(November,  1901),  to  which  subsequently  there  was  added  continuous 
pain  in  the  region  of  the  gall-bladder ;  the  gall-bladder  was  palpable  and 
on  autopsy  was  found  to  be  greatly  distended. 

Jaundice  appeared  soon  after  the  initial  subjective  complaints  (mid- 
dle of  December,  1901).  The  terminal  discharge  of  blood  with  the  feces 
could  suggest  a  primary  ulcerative  process  in  the  stomach  or  duo- 
denum ;  the  fact  was  that  the  cancer  of  the  pancreas  had  invaded 
the  duodenum. 


CARCINOMA    OF    THE    PANCREAS  331 

Autopsy  disclosed  healed  tuberculosis  of  the  j)uliiH)iuiry  apices,  a  find- 
ing not  rare  in  coiuieetion  with  carcinoma,  especially  at   a  younger  age. 

Case  4. — L.  A.,  64  years,  M. 

ad  1. — Mother  died  from  weakness  of  old  age;  obesity  a  family 
trait. 

ad  3. — At  eight  years  of  age,  while  living  in  a  flooded  district  had 
fcA'er  for  a  year  and  a  half. 

ad  5. — Was  otherwise  always  healthy. 

ad  6. — On  October  23,  1905,  suddenly  became  sick  with  dizziness, 
nausea  and  vomiting;  lost  consciousness  for  half  an  hour.  Before  that  he 
had  become  very  much  excited  and  had  worked  seventeen  nights  in  suc- 
cession. Since  then  there  is  great  thirst  (drinks  3  to  4  litres  daily)  and 
correspondingly  increased  diuresis ;  likewise  constipation.  Eructation 
after  every  intake  of  food  or  fluid.  There  is  a  feeling  of  pressure  in  the 
right  half  of  the  abdomen,  and  when  lying  on  the  left  side  there  is  the  un- 
pleasant sensation  of  something  sinking  toward  the  left  side.  Since  the 
beginning  of  the  disease,  languor  and  easy  fatigue.  Emaciation  to  the 
extent  of  26  kg  in  ten  weeks.    Anorexia. 

ad  7. — Habitus  apoplecticus,  reddening  of  the  face.  Right  half  of 
the  abdomen  moderately  sensitive  to  pressure.  The  right  portion  of  the 
liver  extending  downward  three  finger  breadths,  very  hard.  Spleen  hard, 
extends  to  the  costal  arch.  Tongue  slightly  indented.  No  edema  at  the 
ankles. 

Urine:  Averages  4.9%  dextrose,  after  fasting  2.3%.  Acetone  abun- 
dant.   Acetic  acid  reaction  present.    Patellar  reflex  absent. 

ad  8.— Beginning:  October  23,  1905. 

Status  presens:  January  13,  1906. 
Autopsy:  February  1,  1906. 
Duration:  About  3  months, 

ad  9. — Autopsy  (Docent  Dr.  A'.  Landsfeiner)  :  Carcinoma  in  the 
tail  of  the  pancreas ;  confluent  metastases  in  the  right  portion  of  the 
right  hepatic  lobe.    Splenic  tumor  due  to  congestion. 

Epicrisis:  After  an  acute  attack  of  syncope  there  appeared  in  this 
64-year-old  individual  with  inherited  obesity,  diabetic  symptoms,  viz., 
polydypsia  and  polyuria  and  rapid  loss  of  weight. 

The  tongue  showed  indentations,  a  symptom  which  I  am  inclined  to 
look  upon  generally  as  a  stigma  of  constitutional  inferiority. 

Malignant  disease  was  from  the  start  suggested  by  the  following: 

1.  Anorexia,  which  in  a  diabetic  patient  is  always  a  remarkable 
symptom. 

2.  The  existence  of  a  left-sided  "painful  position"  in  so  far  as  lying 
on  the  left  side  produced  extremely  unpleasant  sensations  in  the  right 
half  of  the  abdomen;  moreover,  lying  on  tlie  right  side  was  also  painful, 
evidently  on  account  of  direct  pressure  on  the  cancerously  diseased  liver. 


332  TUMORS    OF    THE    ABD0:MINAL    VISCERA 

Case  5.— A.  H.,  67  years,  M. 

ad  3. — Had  sniallpox  at  12  years  of  age. 
ad  5. — Was  otherwise  always  healthy. 

ad  6. — First  felt  sick  in  the  beginning  of  November,  1908.  There 
began  pain  undet-neath  the  right  costal  arch  and  in  the  lumbar  region, 
there  supervened  vomiting  and  chill. 

ad  7. — Severe  icterus.  Gall-bladder  greatly  enlarged,  visible ! 
Moves  dowTiward  and  inward  with  respiration,  and  with  the  patient  in  left 
lateral  position  it  seems  to  lie  partly  to  the  left  of  the  middle  line.  Ten- 
derness to  pressure  in  the  middle  of  the  epigastrium  underneath  the  costal 
arch.     Tongue  indented.     Afebrile  course.     No  edemas. 

Urine:  Abundance  of  bilirubin;  aldehyde  and  indican  reaction  is 
negative. 

Feces:  Colored  brown  (with  icterus  of  high  degree!)  ;  cause  of  brown 
coloration :  abundant  blood-coloring  matter.  Besides  soap-needles  also 
neutral  fat  globules. 

ad  8. — Beginning:  Early  in  November,  1908. 
Status  presens :  November  21,  1908. 
Autopsy:  December  12,  1908. 
Duration :  About  1  month, 
ad  9. — Autopsy   (Pros.  Professor  Dr.  Fr.  Schlagenhaufcr)  :  Car- 
cinoma of  the  head  of  the  pancreas  invading  the  descending  and  horizontal 
portions  of  the  duodenum  and  ulcerating  in  the  latter  places.    Metastases 
in  the  liver  and  the  ligament  between  tlie  liver  and  duodenum.    Compres- 
sion of  the  ductus  cholcdochus.    Icterus. 

Epicrisis:  The  patient  was  first  brought  to  a  realization  of  his  disease 
by  the  appearance  of  pain  underneath  the  costal  arch  produced  by  vomit- 
ing and  chill  and  the  occurrence  of  jaundice. 

The  gall-bladder  was  found  to  be  greatly  enlarged  and  could  be  seen 
behind  the  abdominal  wall,  following  the  excursions  of  the  diaphragm. 

Despite  severe  jaundice  and  despite  a  negative  aldehyde  reaction  in 
alcoholic  extract  of  stool,  the  feces  were  colored  almost  a  normal  brown. 
Chemical  examination  of  the  feces  furnished  the  explanation :  blood- 
coloring  matter  constantly  strongly  positive.  Autopsy:  Carcinoma  of  the 
pancreas  perforating  into  the  duodenum  and  there  ulcerating.  Indican 
reaction  absent  from  the  urine. 

As  in  Case  4,  so  also  here,  "indented"  tongue. 


Case  6.— U.  P.,  39  years,  F. 

ad  5. — For  the  past  six  years  has  been  "ailing  in  the  lower  ab- 
domen" ;  had  frequent  genital  hemorrhages,  which  ceased  after  curette- 
ment.  She  claims  that  since  that  time  she  has  a  purulent  discharge  from 
the  vagina. 

ad  6.- — In  the  beginning  of  December,  1909,  there  appeared  severe 
pain  in  the  back  and  in  the  abdoBien ;  lately  severe  vomiting,  disturbed 
sensorium.  The  husband  of  this  patient  noticed  a  certain  rigidity  of  the 
spinal   column.    On   account   of   a   suspected   meningitis   the  patient   was 


CARCINOMA    OF    THE    PANCREAS  333 

transferred  to  my  division   from  the  gynecological  division  where,  until 
very  recently,  she  had  been  treated  for  a  right-sided  infiltration. 

ad  7. — Pale  color  of  the  face  with  a  yellowish  tint;  temperature  a 
little  over  38°  C. ;  sensorium  slightly  disturbed.  Dry  tongue.  Abdomen 
distended,  vc#y  sensitive  to  pressure ;  dulness  in  both  flanks.  The  patient 
always  maintains  the  dorsal  position.  Legs  edematous,  the  left  more  so 
than  the  right.    Slight  hematemesis. 

Urine:  Pyuria  containing  bacteria  coli.  Diazo  reaction  entirely  nega- 
tive; so  also  aldehyde  reaction. 

Stool:  Blood-test  negative;  neither  neutral  fat  globules  nor  soap- 
needles. 

Blood:  33,000  leucocytes.    Toward  the  end  erysipelas  of  tiie  fac(f. 
ad  8. — Beginning:  Early  in  December,  1909. 
Status  presens :  December  28,  1909. 
Autopsy:  December  30,  1909. 
Duration :  1  month, 
ad  9. — Autopsy   (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Car- 
cinoma of  the  pancreas  ;  very  extensive  metastases  in  the  mesentery  and 
the   entire   retroperitoneal   cellular   tissue   through   which   the  vena   cava 
and  aorta  take  their  course.    Metastases  in  the  pouch  of  Douglas,  the 
right  parametrium,  the  left  ovary,  perforation  into  the  renal  pelvis.    In- 
filtration of  the  right  suprarenal  body.    Serosanguineous  ascites. 

Epicrisis:  The  resistance  in  the  right  parametrium  which  evidently, 
in  view  of  the  repeated  gynecological  diseases,  had  been  considered  as  of 
inflammatory  nature,  was  in  reality  a  cancer  metastasis.  And  the  pain 
lately  existing  in  the  back  and  in  the  lower  abdomen,  which  were  also  re- 
ferred to  the  genitalia,  were  due  to  the  extensive  retroperitoneal  tumor- 
masses. 

The  high  fever  and  the  hyperleucocytosis  (33,000)  were  explained  by 
the  subsequent  terminal  erysipelas. 

Notwithstanding  the  extensive  carcinomatous  infiltration  of  the  pan- 
creas the  ductus  choledochus  had  remained  intact. 

The  bile-ducts  were  perfectly  free;  there  was  not  even  a  trace  of  a 
positive  aldehyde  reaction.  Examination  of  the  feces  did  not  offer  the 
least  clue  for  assuming  a  disease  of  the  pancreas. 

This  case  had  given  the  appearance  of  a  gynecological  disease,  a  mis- 
take which  may  occasionally  occur  also  in  the  visceral  forms  of  cancer 
(stomach-intestine-gall-bladdcr !)  when  metastases  occur  in  the  true  pel- 
vis giving  rise  to  tumor-masses  which  can  be  palpated  through  the  vagina 
or  through  the  rectum. 

Furthermore,  as  a  result  of  the  erroneous  assumption  of  an  inflam- 
matory gynecological  process  in  the  parametrium  there  was  close  to  hand 
the  thought  of  a  purulent  peritonitis. 


Malignant  Tumors  of  the  Kidneys 

Case  1.— E.  D.,  44  years,  M. 

ad   1. — Both  parents  died  of  apoplexy. 

ad  2. — At  three  years  of  age  had  cervical  adenitis,  at  the  same 
time  had  an  eruption  of  the  scalp. 

ad  5. — At  24  had  gonorrhea  and  orchitis ;  otherwise  was  always 
well.    Six  years  ago  suffered  a  fall  on  his  back. 

ad  6. — Since  about  October,  1900,  frequent  pain  along  the  outer 
side  of  the  right  lower  extremity,  especially  in  the  evening  after  having 
moved  around  a  great  deal  during  the  day.  One  day  in  February,  1902, 
after  eating  there  was  severe  pressure  anteriorly  in  the  abdomen  at  about 
the  height  of  the  umbilicus ;  this  was  relieved  by  vomiting  and  the  next 
day  he  felt  perfectly  well.  Eight  days  later  there  was  a  similar  attack. 
On  March  3,  1902,  after  eating  he  experienced  a  violent  attack  of  cramps 
in  the  right  half  of  the  abdomen  at  the  height  of  the  umbilicus;  vomiting 
followed  and  kept  on  through  the  entire  night;  in  the  morning  the  pain 
disappeared,  the  patient  felt  very  much  exhausted  during  the  next 
two  days. 

On  March  6,  1902,  at  11  p.m.,  extremely  violent  cramp-like  pain, 
radiating  into  the  right  testicle  with  a  sensation  of  a  swelling  in  that 
organ ;  urine  dark,  pronounced  by  a  physician  to  contain  blood.  In  the 
morning  at  6  o'clock  the  pain  disappeared  quite  suddenly  and  the  patient 
felt  well  until  the  end  of  July,  1902.  At  that  time  thei'e  gradual!}'  ap- 
peared pain  in  the  back,  especially  on  the  right  side ;  continuous  dull 
pressing  pain  in  the  right  half  of  the  abdomen.  The  pain  increased  so 
much  that  the  patient  could  neither  stand,  nor  sit,  nor  walk  about ;  he 
felt  best  when  resting  quietly  on  his  back.  When  lying  on  the  left  side  the 
symptoms  become  extremely  severe :  an  unbearable  "pulling"  occurs  in 
the  right  half  of  the  abdomen,  "as  if  something  heavy  was  pressing 
toward  the  middle."  The  urine  is  remarkably  dark  on  and  off.  Decrease 
of  appetite,  great  emaciation  (IT  kg  in  a  few  weeks)  and  feeling  of 
weakness. 

ad  7. — Cachexia :  edema  only  toward  the  end.  Corresponding  to 
the  right  kidney  there  can  be  felt  a  round,  hard  tumor,  the  lumbal  region 
being  tender  on  pressure  and  percussion.  At  times  there  is  pain  in  the 
back,  occasionally  stabbing  sensations  in  the  right  thigh. 

October  18,  1902:  During  the  night  sudden  extremely  violent  pain  in 
the  left  hypochondrium  accompanied  by  vomiting  and  discharge  of  bloody 

334 


MALIGNANT    TUMOKS    OF    THE    KIDNEYS  3:i5 

urine.      Discliarge    of    worm-like    clots.      Blood    pressure    80    inin    Hg. 
(Gartner). 

October  26,  1902:  Retention  for  twenty-four  hours;  500  cm"  ""cotfee- 
ground-liive"    urine    were    withdrawn    by    means    of    a    catheter;    biliary 

I  vomiting. 

I         Vrinarij  sediment:  October  27,  1902:  Many  casts,  including  some  hav- 

!ing  a  wax-like  appearance;  besides  hyaline  casts  and  cylindroids ;  granu- 

ilar  casts  covered  with  renal  epithelium  and  erythrocytes.    Fat  droplets 
and  fatty  acid  needles. 

!  ad  8. — Beginning:  February,  1902. 

I  Status  presens:  October,  1902. 

I  Autopsy:  October  28,  1902. 

;  Duration :  About  8  months. 

ad  9. — Autopsy  (Hofrat  Professor  Dr.  A.  Weichselbaum)  :  Pri- 
mary alveolar  sarcoma  of  the  right  kidney,  grown  into  the  right  renal 
vein  and  the  inferior  vena  cava  and  metastases  into  both  pleurse,  into  the 
bronchial  lymph-nodes  and  into  the  lymph-nodes  at  the  hilum  of  the 
kidney.  Old  hemorrhages  in  the  pelvis  of  the  right  kidney  and  blocking 
of  the  opening  into  the  right  ureter.  Acute  parencli3aiiatous  nephritis  on 
the  right  side.  Continued  thrombosis  of  the  vena  cava  inferior  and 
iliac  vein. 

Epicrlsis:  Even  though  the  existence  of  a  hypernephroma  could  first 
be  told  with  certainty  in  February,  1902  (right-sided  ureteral  colic), 
there  is  yet  the  suspicion  that  the  neuralgic  sensations  experienced  on  the 
outer  side  of  the  right  lower  extremity  about  two  years  before  death, 
were  radiating  pains  of  renal  origin. 

The  disease  of  the  right  kidney  manifests  itself  violently  in  February,. 
1902,  at  first  by  rather  indefinite  cramps  in  the  right  side  of  the  abdomen, 
accompanied  by  vomiting;  then,  however,  there  supervene  characteristic 
radiation  into  the  right  testicle  and  hematuria.  From  March  until  the 
end  of  July,  1902,  there  follows  a  deceptive  intermission,  during  which 
the  patient  feels  w^ell. 

Only  in  October,  1902,  the  cachectic  appearance  and  the  demonstra- 
tion of  a  palpable  hard  renal  tumor  compels  us  to  make  the  right  diag- 
nosis of  a  renal  neoplasm  after  having  previously  diagnosed  the  case  as 
nephrolithiasis. 

The  existence  of  a  left-sided  "painful  position,"  with  distinct  sensa- 
tions of  pulling  in  the  abdomen  are  worthy  of  note. 

The  finding  in  the  sediment  is  that  of  a  chronic  parenchymatous 
nephritis  (waxy  casts,  fat  droplets  and  fatty  acid  needles!);  there  is 
lacking,  however,  hypertrophy  of  the  left  side  of  the  heart,  and  the  blood- 
pressure  is  below  normal. 

The  pain  in  the  left  side  of  the  back  occurring  in  October,  1902,  is 
perhaps  referable  to  the  thrombosis  found  at  autopsy  in  the  left  renal 
vein,  and  edema  of  the  legs  occurring  two  days  before  death  are  very 
likely  due  to  thrombosis  in  the  inferior  vena  cava.  Death  was  accom- 
panied by  uremic  manifestations. 


336  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Case  2. — J.  M.,  66  years,  M.    Mining  inspector. 

ad   1. — Parents  died  at  a  very  old  age. 

ad  3. — Is  said  to  have  had  typhoid  (?)  for  two  weeks  during 
childhood. 

ad  5. — In  1873,  at  the  age  of  36,  during  violent  headache,  sudden 
syncope ;  soon  after  profuse  vomiting  of  blood  (about  2  litres  !).  Later  on, 
while  staying  in  Hungary,  had  malaria  for  nine  months  ;  when  53  years 
of  age  had  one  leg  amputated  on  account  of  caries  of  the  ankle-joint. 

He  says  that  in  5s^ovember,  1902,  his  stools  were  tarry  and  fluid. 
Anorexia  with  much  eructation  after  meals. 

Since  January,  1903,  cutting  pain  in  the  left  half  of  the  epigastrium, 
accompanied  by  "rolling,"  with  occasional  bulging  at  the  point  of  the 
pain.    Emaciation  from  64-  to  52  kg;  great  feeling  of  weakness. 

ad  6. — Toward  the  end  of  April,  1903,  the  patient  noticed  a  swell- 
ing underneath  the  left  costal  arch,  since  which  time  it  has  become  larger. 
Lying  on  the  left  side  is  very  badly  tolerated. 

ad  7. — Sallow  complexion,  with  capillary  dilatations  on  the  cheeks; 
no  edemas.  On  the  left  side,  underneath  the  costal  arch,  a  tumor  can  be 
felt  after  the  manner  of  an  anterior  pole  of  the  spleen,  the  surface  being 
somewhat  uneven  ;  this  tumor  can  be  displaced  3  finger  breadths  over  the 
middle  line  toward  the  right;  when  the  patient  is  lying  on  his  back  the 
tumor  is  distinctly  ballottable,  but  this  is  not  possible  when  lying  on  the 
right  side ;  there  is  good  respiratory  mobility.  A  muffled  tympanitic 
resonance  on  percussion  over  the  tumor-mass.  With  maximal  right  lateral 
position  of  the  patient  it  is  possible  to  penetrate  between  the  tumor-mass 
and  the  left  costal  arch,  and  in  this  way  grasp  the  tumor  from  above. 
No  tenderness  on  pressure  or  on  percussion  over  the  right  hmibar  region. 
Blood  pressure  subnormal. 
Urine:  Negative  finding. 
Blood:  4,500  leucocytes. 

ad  8.— Beginning:  End  of  April,  1903. 
Status  prescns :  May  29,  1903. 
Operation:  June  5,  1903. 

ad  9. — Finding  at  operation  (Clinic  of  the  late  Hofrat  Professor 
K.  Gussenhauers;  Docent  Dr.  D.  Pupovac)  :  Tumor,  as  big  as  a  child's 
head,  springing  from  the  inferior  pole  of  the  kidney.  Histological  exam- 
ination :    Tumor  of  Grawitz. 

Epicriftis:  Descended  from  longlivcd  parents,  this  66-year-old-patient 
had  had  malaria,  in  1873  had  acquired  an  ulcer  of  the  stomach,  and  at 
the  age  of  53  had  been  operated  on  for  caries  of  the  ankle-joint.  In 
November,  1902,  there  seems  to  have  been  renewed  hemorrhage  from  ulcer 
with  the  addition  of  gastric  symptoms  bearing  an  ulcerous  stamp.  At 
first  one  would  have  been  inclined  to  look  upon  the  palpable  tumor  under 
the  costnl  nrch  as  springing  from  the  stomach.  Still,  there  was  distinct 
ballottement,  at  least  with  the  patient  in  the  dorsal  position ;  in  the  right 
lateral  position  the  tumor  left  the  lumbar  region  and  moved  toward  the 
median  line,  so  that  in  this  position  ballottement  was  not  obtainable. 

The  fact  that  the  tumor  could  be  grasped  from  above  distinguished 


MALIGNANT    TUMORS    OF    TIIK    KIUXEVS  337 

it  from  a  palpuhlc  jjole  of  the  spleen,  also  there  was  absent  a  correspond- 
ing splenic  dulness.  The  examination  of  the  urine  proved  negative,  both 
chemically  and  microscopically. 

Case  3.— M.  W.,  47  years,  M.    Peddler, 
ad  1. — No  hereditary  taint, 
ad  3. — Typhoid  at  5  years  of  ago. 
ad  5. — At  26  had  jaundice  for  tvi^o  months. 

ad  6. — In  March,  1899,  while  pulling  a  heavy  hand  sleigh,  experi- 
enced a  sudden  stitch  in  the  right  lumbar  region;  for  the  following  three 
months  he  still  noticed  that  on  stooping  there  was  a  stabbing  pain  in  that 
region  covering  an  area  about  the  size  of  the  palm  of  the  hand.  After 
that  he  felt  entirely  well. 

In  February,  1903,  without  any  external  provocation,  dragging  })ain 
in  the  right  hip  corresponding  to  the  course  of  the  sciatic  nerve.  Dura- 
tion :  1  month. 

About  the  middle  of  ^Nlarch,  as  a  result  of  carrying  heavy  loads,  pain 
in  the  right  lumbar  region  the  same  as  in  March,  1899.  When  working 
in  a  stooped  attitude  he  could  straighten  himself  only  with  difficulty  and 
had  to  walk  about  in  a  stooped  position  for  some  time.  This  pain  has 
continued  since  then. 

Since  the  middle  of  April,  1903,  about  a  quarter  of  an  hour  after 
every  big  meal  there  are  pressing  pains  in  the  epigastrium,  lasting  about 
two  hours;  aggravated  by  motion  and  left  lateral  position.  Frequent  sour 
eructation.  Appetite  good,  bowels  regular.  The  epigastric  sensation  of 
pressure  depends  only  on  the  quantity  of  digested  food,  and  is  uninflu- 
enced by  the  quality  of  it.  From  the  spring  of  1903  until  October,  1903, 
the  loss  in  weight  amounted  to  5  kg. 

On  September  7,  1903,  despite  tenesmus,  inability  to  urinate,  only 
after  several  minutes  of  much  straining  the  voiding  of  urine  takes  place; 
urine  not  bloody. 

ad  7. — Facial  color  is  cachectic,  with  a  yellowish  tint ;  no  edemas. 
On  the  right  side,  underneath  the  costal  arch,  there  is  a  palpable  tumor- 
mass  corresponding  in  its  form  to  the  lower  pole  of  the  kidney,  being 
smooth,  not  sensitive  to  pressure,  of  moderately  firm  consistence;  distinct 
ballottement ;  in  front  of  the  tumor  a  soft  cord  can  be  felt  (colon!).  A 
distinct  systolic  murmur  is  audible  above  the  tumor.  Right  lumbar  region 
slightly  tender  to  pressure;  on  the  right  side  at  base,  a  dry  catarrh. 
The  spleen  extends  one  finger's  breadth  beyond  the  costal  arch.  Slight 
aortic  insufficiency.  Bilateral  varicocele.  Temperature  often  subnormal 
(36°  C). 

Urine:  Quantity  normal,  color  very  light.  No  serum-albumin,  not  even 
in  traces. 

Sediment:  Extremely  scanty,  finely  flocculent.  Isolated  erythrocyte 
shadows ;  in  two  preparations  there  was  found  a  single  cast  composed  of 
discolored  erythrocytes  and  renal  epithelial  cells.  Continued  finding  of 
uric  acid  sediment,  transiently  many  oxalates. 

Stomach  contents:  HCl  positive. 


338  TUMORS    OF    THE    ABDOMINAL    VISCERA 

Blood:  4<,6{)(),00()  erythrocytes,  5,600  leucocytes,  TO'/c  hemoglobin. 
November  5,  1903:  During  the  past  weeks  has  gained  4.5  kg  in  weight ; 
no  edemas.    Only  on  walking  mild  pain  in  the  right  flank ;  at  the  place 
where  the  tumor  is  distinctly  palpable  there  is  a  loud  systolic  murnmr. 
ad  8.— Beginning:  March,  1899  (?). 

Status  presens :  October  3,  1903. 
Autopsy:  November  20,  1903. 
Duration :  Over  4>  years, 
ad  9. — Autopsy    (Professor  Dr.   0.  Stoerk)  :   Extirpation   of  the 
right  kidney  on  account  of  a  tumor  of  Grawitz  eleven  days  ago.    Tumor 
metastases   in   the  lungs   and   the    retroperitoneal   lymph-nodes.      Tumor 
thrombosis  in  the  ascending  cava  from  the  entrance  of  the  renal  vein  up- 
ward.    Atheroma  of  the  aorta  and  insufficiency  of  the  semilunar  valves. 

Epicrisis:  One  is  inclined  to  assume  that  the  pains  in  the  right  lumbar 
region  occurring  in  March,  1899,  and  continuing  for  three  months  were 
of  renal  origin,  according  to  which  tiie  duration  of  the  disease  would  ex- 
ceed four  years. 

In  the  case  of  hypernephromata  in  particular,  it  is  a  cert;iin  fact  that 
they  may  for  a  long  time  act  like  benign  new  formations. 

In  February,  1903,  there  also  appeared  sciatic  pain  on  tiie  right  side. 

In  March,  1903,  there  was  a  repetition  of  the  right-sided  lumbar  pain 
occurring  in  1899.  Stooping  becomes  extremely  painful.  A  troublesome 
feeling  of  pressure  comes  on  especially  after  big  meals  (obstruction  of 
the  pyloric  passage  on  part  of  the  tumor-mass.''). 

The  systolic  murmur  which  can  be  heard  in  the  right  flank  over  the 
tumor  is  very  worthy  of  note;  it  is  probably  due  to  the  vascularity  of  the 
tumor-mass  itself. 

The  color  of  the  face  with  its  yellow  nuance  is  reminiscent  of  findings 
frequently  met  with  in  especially  gastric  cancers  ("Teint  paille  jaune"). 

Blood  and  serum-albumin  were  absent  from  the  urine  until  the  end ; 
while  the  quantity  of  the  urine  was  normal,  its  color  was  remarkably 
light. 

This  case  shows  how  important  it  is  in  such  cases  to  make  an  exact 
microscopical  examination,  even  though  the  chemical  findings  are  negative. 
In  the  extremely  scanty  sediment  there  were  fovnul  erythrocyte  shadows 
indicating  "occult"  bleeding,  and  there  was  also  found  one  cast  covered 
with  erythrocytes  and  renal  epithelial  cells. 

During  the  very  last  days  the  patient  had  gained  -tl/)  kg  in  Avcight 
without  the  appearance  of  anasarca  or  hydrops. 

Autopsy  disclosed  a  finding  which  is  frequent  in  connection  with 
hypernephromata,  namely  rupture  into  the  corresponding  renal  vein  and 
thence  into  the  inferior  cava. 

Case  4. — J.  K.,  53  years,  F. 

ad   1. — Father  is  73  years  of  age. 

ad  3. — Has  had  no  infectious  diseases  of  childhood. 

ad  5. — Hemopt^^sis  at  43  years  of  age  (about  ^  litre  of  blood)  : 
since  then  often  has  cough  during  the  cold  seasons. 


MALIGNANT    TUMORS    OF    THE    KIDNEYS  JiJii) 

ad  6. — At  Cliristnias,  1904,  tliere  began  stveio  pain,  without  colicky 
character,  radiating  from  the  sacrum  toward  the  lumbar  region  and  the 
gluteal  region,  sometimes  to  the  right,  sometimes  to  the  left.  When  the 
pain  is  on  the  left  side  the  patient  walks  about  inclining  toward  the  left 
and  the  reverse.  When  the  pain  is  on  the  left  side,  left  lateral  position  is 
better  tolerated.  During  the  attack  of  pain  the  urine  is  said  to  be  colored 
brown,  at  which  times  the  patient  usually  urinates  about  three  times  dur- 
ing the  night,  whereas  otherwise  she  never  voids  urine  at  night.  When  the 
pain  is  very  intense  it  radiates  toward  the  shoulder-blade.  Since  Christ- 
mas, 1904,  emaciation  to  the  extent  of  5  kg. 

In  May,  1905,  the  patient  left  the  clinic,  felt  quite  well  and  gained 
4  kg  in  several  weeks.    She  worked  and  felt  no  weakness. 

On  July  20,  1905,  there  again  began  pain  in  the  left  flank  "like 
toothache."  The  pain  became  very  severe,  extending  downward  into 
the  right  thigh  (as  far  as  the  knee),  upward  to  the  left  shoulder- 
blade,  anteriorly  into  the  epigastrium.  No  cramp-like  pain,  sensa- 
tion of  burning.  With  severe  pain  there  was  a  breaking  out  of 
sweat,  repeated  urgent  desire  to  urinate,  only  a  few  drops  being 
voided,  accompanied  by  burning,  at  times  also  nausea.  The  pain  in- 
creased when  lying  on  the  right  side,  so  that  the  patient  rests  on  the 
painful  side.  At  present  (July,  1905)  the  pain  is  continuous,  becoming 
increased  in  the  evening. 

In  May,  1905,  entirely  analogous  pain  had  existed  on  the  right  side. 
Good  appetite  for  meat. 

ad  7. — May  20,  1905:  Afebrile  course;  no  edemas.  Corresponding 
to  the  left  kidney,  especially  when  lying  on  the  right  side,  a  very  firm, 
uneven  tumor  can  be  felt.  The  left  lumbar  region  yields  dulness  on  per- 
cussion, on  the  right  there  is  tympany.  The  urine  is  very  light,  contains 
no  trace  of  serum- albumin  or  blood, 

July  29,  1905  :  Tumor  is  very  slightly  tender  on  pressure,  distinctly 
ballottable,  hard  percussion  of  the  left  lumbar  region  is  not  painful.  In 
front  of  the  tumor,  bowel  splashing  is  audible.    No  edemas. 

Urine:  Abundant  urobilin  (chronic  constipation!).  The  sediment  con- 
tains a  moderate  abundance  of  pus-cells,  which  partly  contain  yellowish 
crystals  (hematoidin?),  and  partly  brown  pigment  granules.  No  ery- 
throcytes.   1/4%  serum-albumin. 

Ureteral  catheterization:  Urine  from  the  left  ureter:  traces  of  al- 
bumin, finely  flocculent,  brownish  sediment  consisting  of  heaps  of  ery- 
throcyte shadows  and  granulated  detritus. 

Urine  from  the  right  ureter :  Traces  of  albumin ;  very  scanty,  finely 
flocculent  sediment  without  distinct  coloration ;  extremely  scanty  ery- 
throcyte shadows. 

ad  8. — Beginning:  Christmas,  1904. 

Status  presens :  May  20,  1905,  and  July  29,  1905. 
Autopsy:  August  31,  1905. 
Duration :  About  9  months, 
ad   9. — Autopsy  (Decent  Dr.  J.  Bart  el)  :  Partial  extirpation  of  a 
tumor  of  the  left  kidney. 


340  TUMORS    OF    THE    ABDOMINAL    MSCERA 

Histological  exaniination  (Professor  Dr.  A.  Ghon)  :  Vascular  spindle- 
cell  sarcoma. 

Epicrisis:  In  this  case  the  phenomena  of  pain  appear  prominently  in 
the  foreground ;  being  localized  in  the  left  side  of  the  abdomen,  they  be- 
tray their  renal  origin  by  occasional  radiation  into  the  thigh  of  the  same 
side,  tenesmus,  and  change  in  the  color  of  the  urine.  In  accordance  with 
their  intrarenal  genesis  they  lack  a  colicky  character.  There  is  present  a 
left-sided  "painful  position."  The  not  inconsiderable  gain  in  weight 
(4  kg)  during  the  course  of  the  disease  is  deserving  of  note.  The  relation 
of  the  bowel  to  the  tumor-mass  is  made  clear  by  the  presence  of  splashing 
in  front  of  the  tumor.  The  changes  in  the  urine  arc  very  slight :  We  find 
traces  of  albumin  and  erythrocyte  shadows,  for  the  first  time,  toward  the 
end  of  the  disease,  particularly  in  tiie  urine  obtained  from  the  left  kidney. 

Case  5. — K.  P.,  53  years,  F. 

ad  5. — Was  always  healthy,  the  only  sickness  she  had  was  pneu- 
monia. 

ad  6. — In  the  beginning  of  April  of  this  year  (1908)  tiiere  ap- 
peared severe  headaches,  accompanied  by  dizziness ;  there  followed  weak- 
ness and  loss  of  sensation  in  the  right  upper  extremity,  so  that  she  could 
not  retain  her  grasp  on  objects.  Soon  there  followed  analogous  manifes- 
tations in  the  riglit  lower  extremity.  The  weakness  soon  changed  into 
complete  paralysis ;  inability  to  speak.  Consciousness  remained  unclouded. 
About  the  middle  of  April  of  this  year  (1908),  two  weeks  after  the  ap- 
pearance of  paralysis,  a  })r()fuse  hemorrhage  occurred  from  the  vagina 
during  defecation. 

ad  7. — Pale  color  of  the  face;  sensorium  unaffected,  crying  mood. 
Relaxed  paralysis  of  the  right  arm  and  the  right  leg;  Babinski's   reflex 
positive  on  the  right  side;  patellar  reflex  weaker  on  the  right.    Indication 
of  cervical  rigidity.    The  head  greatly  everted  to  the  left.    Slight  spasms 
in  the  left  upper  extremity.    Crater-like  ulcer  on  the  left  side  at  the  en- 
trance to  the  vagina.   Loud,  almost  grating  systolic  murmurs  over  all  the 
cardiac  orifices;  arteries  delicate,  blood-pressure  normal.    On  the  right, 
under  the  costal  arch,  the  liver  is  drawn  out  after  the  manner  of  a  "corset 
lobe,"  consistence  but  little  increased,  surface  smooth. 
Blood:  Hemoglobin  1007^  ;  leucocytes  9,600. 
Toward  the  end,  temperature  up  to  40°  C. 
ad  8. — Beginning:  Early  part  of  April,  1908. 
Status  presens:  May  15,  1908. 
Autopsy:  May  19,  1908. 
Duration:  About  6  months, 
ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Schlagenhaufer)  :  Tumor 
of  Grawitz,  as  big  as  a  fist,  belonging  to  the  left  kidney  (inferior  pole) 
with  multiple  metastases  in  the  liver,  in  both  lungs,  in  the  right  kidney, 
in  the  glands  of  the  hilum.    Several  metastases  in  the  cerebrum  and  cere- 
bellum and  in  the  posterior  wall  of  the  vagina. 

Epicrisis:  This  case  illustrates  how  a  tumor  of  Grawitz  may  occa- 
sionally,  as   a   result    of  metastases*  in   the   brain,   make   its   appearance 


MALIGNANT    TUMORS    OF    THE    KIDNEYS  3-H 

under  the  aspect  of  a  gradual  paralysis.  The  metastasis  situated  in  tlie 
right  lobe  of  the  liver  was  of  extraordinary  soft  consistence,  which  ren- 
ders the  recognition  of  such  metastases  difficult  during  life. 

The  combination  of  hemiplegia  and  hemorrhage  per  vaginani  had  in- 
duced me  to  think  of  the  possibility  of  a  malignant  process  of  the  geni- 
talia with  metastases  in  the  brain.  Examination  of  the  genitalia  actually 
revealed  a  crater-like  ulcer  on  the  left  side  in  the  vaginal  entrance.  It 
was  only  at  autopsy  that  the  primary  focus  in  tiie  lower  pole  of  the 
kidney  was  found. 

Case  6.— N.  N.,  61  years,  M.    Laborer,  "^s 
ad   1. — No  hereditary  taint. 

ad  2. — Physical  development  retarded  until  his  seventeenth  year, 
ad  3. — Had  malaria  from  1855-1858  while  in  Hungary;  since  then 
has  been  well. 

ad  5. — Toward  the  end  of  1894  the  color  of  his  face  gradually  be- 
came pale,  he  felt  exhausted,  and  glandular  swellings  appeared  on  the 
neck. 

ad  6. — In  the  spring  of  1895  there  were  added  pain  in  the  back, 
which  radiated  particularly  into  the  right  lower  extremity. 

On  September  14,  1895,  blood  appeared  in  the  urine;  the  admixture 
of  blood  disappeared  in  two  days. 

In  October,  1895,  there  was  swelling  of  the  lower  extremities.  Pro- 
gressive emaciation  since  the  summer  of  1895. 

ad  7.- — General  swelling  of  glands ;  the  glands  are  modcrateh^  firm, 
not  adherent  to  each  other,  in  some  places  attaining  the  size  of  a  hen's 
Ggg.  The  spleen  is  hard,  extends  three  finger  breadths  beyond  the  costal 
arch.  On  the  right  side  corresponding  to  the  kidney,  there  is  an  uneven, 
ballottable  tumor. 

Blood  X October  16,  1895)  :  3,450,000  -erythrocytes,  96,000  leuco- 
cytes, hemoglobin  50%. 

Differential  leucocyte  count:  Mononuclears,  82.3%;  polynuclears, 
15.67c. 

February  27,  1896:  48,000  leucocytes,  viz.:  51%  mononuclears,  457o 
mononuclears. 

Urine:  Albumin  positive;  much  sediment  composed  of  leucocytes. 
December  30,  1895 :  Hematuria  without  pain. 

January  11,  1896:  Discharge  of  a  worm-shaped  clot  about  10  cm  long. 

February  20,  1896:  Discharge  of  a  particle  of  tissue  w^hich  was  1.5 

cm  long  and  1/;^  cm  wide,  which  after  microscopic  examination  (Professor 

Dr.  A.  Kolisko)  was  diagnosed  as  a  shred  from  a  disintegrating  neoplasm. 

ad  8. — Beginning:  Spring  of  1895. 

Status  presens :  October,  1895. 
Autopsy:  March  20,  1896. 
Duration  :  About  1  year. 


Compare  Mdrinrhlcr.   Wiener   Klin.  Wochensciir.,   1896,  No.   .10. 


342  TUMORS    OF    THE    ABDOMINAL    VISCERA 

ad  9. — Autopsy  (March  20,  1896)  :  Perithelioma  carcinomatodes 
supraglaiuhihire  of  the  riglit  kidney  with  proliferation  into  the  ureter 
and  the  inferior  vena  cava,  metastases  in  the  liver,  in  the  lungs  and  in  the 
spinal  column.  Leukemic  hyperplasia  of  the  spleen  and  the  various  lymph- 
glands.  Right  kidney  almost  completely  replaced  by  a  very  soft,  almost 
deliquescent,  vascular  tumor  as  big  as  the  head  of  a  small  child,  rupturing 
into  the  renal  vein  and  projecting  into  the  lumen  of  the  iiifirior  vena 
cava  like  a  very  soft  plug. 

Microscopical  examination:  Typical  picture  of  a  tumor  of  Grawitz. 

Ejncrisis:  In  this  61-year-old  patient  the  right-sided  renal  tumor  of 
Grawitz  was  associated  with  a  lyin})hatic  leukemia,  both  diseases  perhaps 
having  sprung  from  a  congenital  constitutional  defect.  Until  his  seven- 
teenth year  this  patient's  development  had  been  retarded.  Upon  repeated 
examination  of  the  urine  I  found  in  it  in  February  20,  1896,  a  shred  of 
tissue  which  Professor  Dr.  A.  KoUsko  diagnosed  as  coming  from  a  malig- 
nant tumor.  The  assumption  of  a  right-sided  malignant  renal  tumor  har- 
monized with  the  renal  hemorrhage  which  occurred  in  September,  1895. 
In  January,  1896,  a  vermiform  clot  (uretei-al  cast)  had  been  voided.  The 
leucocyte  count  in  the  blood  fluctuated  during  the  course  of  the  disease — 
perhaps  under  the  influence  of  the  malignant  process  in  the  kidney — the 
mononuclears  being,  toward  the  end  of  the  disease,  fewer  in  number  than  at 
the  beirinninir- 


APPENDIX 
"Atypical"  Malignant  Tumors  of  the  Abdomen 

Case  1.— F.  A.,  38  years,  F. 

ad  6. — Beginning  of  disease  in  December,  1899,  with  constipation; 
up  to  four  day  intervals  between  stools.  At  the  same  time  profuse  night- 
sweats.  Menses  had  ceased  since  December,  1899,  and  the  patient  states 
that  the  supervening  enlargement  of  the  abdomen  (ascites!)  was  attrib- 
uted to  pregnancy.  Since  the  appearance  of  the  ascites  there  has  been 
pain  in  the  back  only  on  stooping;  it  disappeared  after  tapping.  At 
the  start  the  appetite  became  good,  becoming  diminished  only  when  there 
were  long  intervals  between  stools.  Only  since  February  of  this  year 
(1900)  anorexia,  eructation  of  gas,  now  and  then  vomiting  in  the  morn- 
ing, especially  after  drinking  cold  water.  Since,  frequently  loud  bowel 
noises,  accompanied  by  pain. 

ad  7. — Severe  cachexia  and  edema  of  the  legs.  Great  ascites,  to- 
gether with  a  left-sided  pleural  effusion  over  an  area  as  big  as  a  hand. 
At  the  height  of  the  umbilicus  a  crescent-shaped  firm  lamina  can  be  felt, 
its  convexity  being  downward,  having  a  sharp  border  with  numerous  in- 
dentations in  it,  continuing  to  the  left  up  to  the  costal  arch;  anterior  to 
it  there  is  a  protuberance  as  big  as  a  nut.  The  vertical  diameter  of  this 
tumor-mass  is  about  three  finger  breadths,  being  about  two  hand  breadths 
wide.  In  the  region  of  this  tumor-mass  distinct  peritoneal  friction  can  be 
heard  and  felt.  Percussion  elicits  a  muffled  tympanitic  note.  Above  this 
crescent-shaped  lamina  there  are  small,  firm,  nodule-shaped  tumors 
(glands  in  the  meso-colon  !). 

Blood:  24-, 000  leucocytes. 

Vaginal  examination:  Distinct  tumor-masses  are  palpable  in  the  para- 
metrium on  the  left  side. 

Rectal  examination:  Nodular  tumor-masses  can  be  felt  through  the 
unaltered  anterior  wall  of  the  rectum. 

Abdominal  fluid  from  tapping;  "milky"  turbidity. 

March  23,  1900:  Pleural  friction  posteriorly  on  the  right  side  below. 
Venous  dilatations  around  the  umbilicus  and  over  the  right  half  of  the 
abdomen.  Frequent  temperature  elevations  above  38°  C.  without  painful- 
ness  in  the  abdomen  (section:  purulent  peritonitis!). 

Since  March  18,  1900.  severe  "white"  edema  of  the  legs  in  the  lumbar 
region  and  the  lateral  belly-wall. 

343 


344  APPENDIX 

Toward  the  end  vomiting  of  bile  and  "coffee-grounds." 
ad   8. — Beginning:  Early  in  December,  1899. 

Status  presens :  March  8  and  March  23,  1900. 
ad  9. — Autopsy  (Docent  Dr.  A'.  Landsteiner)  :  Carcinoma  of  the 
ovaries,  having  for  its  base  papillary  ovarian  cysts  (size  of  eggs)  with  ex- 
tensive metastasis  in  the  peritoneum.  The  omentum  is  thickly  infiltrated, 
and  on  the  serosa  of  the  bowel  and  the  mesentery  there  are  numerous  bed- 
like plaques  of  tumor-masses.  The  uterus  is  surrounded  by  tumor-masses 
and  partly  studded  by  them.  Fibrinous  purulent  peritonitis,  left-sided 
hydrothorax.    P'resh  thrombosis  of  the  portal  vein. 

Epicrisis:  Worthy  of  attention  are  the  profuse  night-sweats  appear- 
ing as  the  first  symptom  of  the  malignant  disease  in  the  ovaries.  Given 
the  same  clinical  picture,  these  sweats  might  occasionally  suggest  tuber- 
culosis of  the  peritoneum.  The  tumor-mass  corresponding  to  the  situa- 
tion of  the  transverse  colon  and  extending,  in  the  shape  of  a  crescent, 
from  one  costal  arch  to  the  other,  was  shown  at  autopsy  to  belong  to  the 
great  omentum. 

Among  the  early  symptoms  there  was  also  constipati(j!i,  w  liich  wa.-.  ac- 
companied by  mild  symptoms  of  stenosis  (loud  bowel  rumbling)  and  which 
was  very  likely  due  to  moderate  compression  of  the  lowermost  segment  of 
the  bowel.  The  gastric  symptoms  (vomiting,  eructation)  nngiit  likewise 
be  traced  to  this  congestion  from  obstruction. 

Toward  the  end  there  supervened  vomiting  of  bile  and  "coffee-grounds" 
due  to  a  painless  })eritonitis,  which  may  have  been  brought  on  by  j)uncture 
incident  to  tapping. 

Case  2.— M.  Z.,  17  years,  F. 

ad   1. — IMother  died  of  tuberculosis. 

ad  6. — Since  the  beginning  of  August  there  has  been  anorexia,  oc- 
casional vomiting,  pressing,  dull  pain  in  the  abdomen  after  eating,  bitter 
eructation  ;  constipation. 

From  November,  1900,  to  March.  1901,  cessation  of  menses. 

Finding  on  November  17,  1900:  A  tumor-mass  extending  two  finger 
breadths  above  the  umbilicus,  occupying  the  entire  width  of  the  abdomen; 
ascites   not  demonstrable. 

On  the  right  side,  luulerneath  the  umbilicus,  there  is  a  portion  of  the 
tumor-mass  as  big  as  the  head  of  a  child,  firm,  hard,  globular,  merging 
with  the  softer  portions  near  the  umbilicus.  The  tumor  is  fixed  against 
the  pelvis.    No  pain  in  the  back. 

Genital  finding:  Infantile  genitals;  tumor-masses  can  be  felt  through 
the  posterior  fornix. 

In  April,  1901,  after  treatment  with  potassium  iodide,  no  tumors  are 
said  to  have  been  demonstrable   (?). 

In  July,  1901,  the  patient  again  entered  a  gynecological  clinic.  A 
nodular  tumor-mass  was  felt  to  the  left  of  the  umbilicus ;  painfulncss  on 
pressure  in  the  epigastrium  and  on  the  right  side  underneath  the  cos- 
tal arch. 


"ATYPICAL"  TUMORS  OF  THE  ABDOMEN     345 

On  July  25,  1901,  an  incision  was  made  in  the  posterior  wall  of  the 
vagina  and  about  1/4  litre  of  a  yellowish,  later  reddish,  fluid  was  evacuated, 
ad  7. — August  3,  1901  :  No  pain  in  the  back.  Patient  complains  of 
severe  pain  on  the  outer  side  of  the  right  tiiigh.  Abdomen  extremely  ten.se, 
dulness  anteriorly,  together  with  fluctuation  ;  venous  dilatations  also  over 
the  sternum.  Linea  alba  much  pigmented,  areola?  of  the  nipples  large  and 
likewise  much  pigmented.  ^  ery  little  indurated  edema  of  the  legs  below 
the  knees.   Afebrile  course. 

ad  8. — Beginning:  Early  in  August,  1900. 
Status  presens :  August  3,  1901. 
Autopsy:  August  14,  1901, 
Duration :  About  1  year, 
ad  9. — Autopsy  (Professor  Dr.  H.  Alb,recht)  :  Medullar}',  mostly 
necrotic  sarcoma  of  the  ovaries,  bigger  than  the  head  of  a  man. 

Eplcrisis:  In  this  17-year-old  girl,  descended  from  a  tuberculous 
mother,  a  gynecologist  had  thought  of  tuberculosis  of  the  peritoneum. 

At  the  time  the  patient  was  received  into  the  clinic  (August,  1901) 
the  rigidity  of  the  abdominal  wall  was  so  great  that  it  was  impossible  to 
obtain  any  finding  by  palpation. 

The  appearance  of  the  disease  with  the  symptoms  of  pseudo-pregnancy 
seemed  remarkable  to  me,  and  this  constituted  my  chief  reason  for  making 
the  diagnosis  of  a  neoplasm  springing  from  the  ovaries. 

Pigmentations  of  the  linea  alba  as  well  as  of  the  areolje  of  the  nipples 
had  occurred  in  the  very  beginning  and  the  menses  had  been  absent  for 
several  months.  In  view  of  this  ensemble  of  symptoms,  a  relative  of  the 
patient  had,  in  the  beginning,  thought  of  pregnancy.  The  stubborn  vomit- 
ing also  could  be  explained  in  this  way. 

The  enormous  tumor-mass  springing  from  the  ovary  fills  almost  the 
entire  abdomen,  which  explains  the  appearance  of  external  collateral  veins 
(also  over  the  sternum!).  The  neuralgias  in  the  right  thigh  are  probably 
to  be  looked  upon  as  symptoms  of  compression ;  pain  in  the  back  was 
permanently  absent.  There  was  no  ascites,  neither  was  there  any  severe 
edema.    The  tumoi*-mass  had  not  been  tender  to  pressure. 

Case  3.— F.  K.,  36  years,  M.    Waiter. 

ad  6. — In  Septcmbei-,  1900,  rapid  enlargement  of  the  left  testicle, 
which  had  been  injured  (blow)  in  Januar}^  1900.  Taken  for  a  hydrocele 
in  the  beginning;  later  resection. 

Since  the  middle  of  January,  1901,  frequently  constipated  for  three 
or  four  days ;  often,  especially  at  night,  colicky  pain  at  the  height  of  the 
umbilicus,  particularly  on  the  left  side,  accompanied  by  borborygmi ;  if 
the  pain  lets  up  anteriorly  it  becomes  worse  in  the  back.  Flatus-produc- 
ing vegetables,  such  as  cabbage,  are  poorly  tolerated.  Appetite  very  good, 
no  vomiting.  Frequent  parietal  headaches,  which  let  up  after  movement  of 
the  bowels. 

ad  7. — Left  inferior  epigastric  vein  somewhat  dilated.  Situated 
chiefly  in  the  left  half  of  the  abdomen  there  is  a  very  hard  and  uneven 
tumor-mass,  bigger  in  size  than  the  palm  of  a  hand  and  firmly  fixed  behind 


346  APPENDIX 

the  peritoneum,  extending  about  tliree  finger  breadths  above  and  below  the 
umbilicus,  reaching  the  mammary  line  on  the  left,  and  going  one  finger 
breadth  to  the  right  of  the  median  line.  A  loop  of  intestine  can  be  rolled 
to  and  fro  on  this  tumor-mass.  Pain  in  the  back  appears  only  at  the 
time  of  intestinal  colics.  Inguinal  glands  not  enlarged.  No  edemas.  Pain 
in  the  back  only  on  stool  retention,  immediate  cessation  after  bowel 
evacuation. 

From  the  decursus: 

March  30,  1901 :  Temperature  rise  up  to  38.5°  C.  and  appearance 
of  glands  in  the  left  axilla  accompanied  by  pain  and  diffuse  swelling  at 
that  site.    Iodine  therapy  caused  a  retrogression  of  these  manifestations. 

April  20,  1901 :  Attacks  of  pain  due  to  flatulence,  accompanied  by 
bradycardia,  nausea  and  rectal  tenesnms,  breaking  out  of  sweat  over  the 
whole  body,  pallor  of  tiie  face,  feeling  of  pressure  in  the  abdomen;  all 
these  symptoms  relieved  after  discharge  of  flatus.  During  the  attack  the 
patient  inclines  forward  and  compresses  the  abdomen, 
ad  8. — Beginning:  September,  1900. 

Status  presens:  March  0,  1901.  and  June  20.  1901. 
Autopsy:  July  6,  1901. 
Duration:  About  10  months, 
ad  9. — Autopsy  (Docent  Dr.  A'.  Landste'iner)  :  Sarcomatosis  of  the 
lymph-glands   following  a  primary  sarcoma  of  the   testicle   (extirpation 
of  the  left  testicle  about  a  year  ago)  ;  large  tumors  of  the  lymph-glands 
with  inclusion  of  the  large  vessels,  compression  of  the  left  kidney  and  the 
small  intestine.    Compression  of  the  left   lobe  of  tiie  thyroid  gland  and 
jugular  vein  by  a  big  tumor.    Compression  of  the  superior  vena  cava  and 
dilatation  of  the  cutaneous  veins  in  the  upper  half  of  the  body. 

Epicrisis:  In  this  36-year-old  patient  the  left  testicle  had  been  extir- 
pated in  September,  1900  (diagnosis:  round  cell  sarcoma). 

About  the  middle  of  January,  1901,  there  appeared  colicky  pains  on 
the  left  side  which,  without  doubt,  are  related  to  the  {)resence  of  left-sided 
retroperitoneal  glandular  metastases  and  are  to  be  interpreted  as  flatulent 
colic. 

These  secondary  bowel  symptoms  were  the  leading  subjective  com- 
plaints until  the  end  and  gave  rise  to  peculiar  manifestations  accompanied 
by  seizures  of  collapse. 

Autopsy  showed  that  in  different  places  the  bowel  was  adherent,  lead- 
ing to  disturbances  in  canalization.  The  retroperitoneal  situation  of  the 
tumor-mass  was  shown  by  its  respiratory  immobility ;  also  loops  of  intes- 
tine were  demonstrable  in  front  of  it. 

During  the  further  course  of  the  disease  there  supervened  metastases 
in  the  glands  of  the  left  axilla,  accompanied  by  manifestations  of  severe 
inflammation,  which,  however,  rapidly  retrogressed. 

Glandular  metastases  also  occurred  in  the  supraclavicular  space  and 
anteriorly  lying  on  the  trachea. 

In  cases  of  tumor-masses  situated  rctroperitoneally  it  will,  therefore, 
be  commendable  occasionally  to  think  of  the  possibility  of  a  primary 
neoplasm  of  the  testicle. 


"ATYPICAL"  TUMORS  OF  THE  ABDOMEN     347 

Case  4. — J.  T.,  50  years,  M. 

ad   3. — Has  luid  no  diseases  of  cliildhood. 

ad  5. — Was  always  healthy.  For  the  past  six  or  eight  years  there 
is  present  an  intumescence  of"  the  right  testicle. 

ad  (). — Toward  the  end  of  March,  1904,  the  appetite  hecanie  had 
and  moderate  constipation  set  in.  There  appeared  a  tendency  to  flatu- 
lence. On  Api-il  1(),  1904,  while  walking,  there  suddenly  appeared  an  enor- 
mous swelling  of  the  left  leg,  the  limb  becoming  black  and  blue  and  was 
very  painful  to  pressure  for  two  weeks. 

ad  7. — Cachectic  appearance;  edema  of  the  left  lower  extremity,  at 
present  no  tenderness  on  pressure.  Abdomen  very  tense,  but  not  appre- 
ciably enlarged.  P^pigastrium  bulging;  dilated  veins  cross  the  left  ligament 
of  Poupart  and  are  also  present  posteriorly  on  the  right  side  near  the 
spinal  colunui.  A  tensely  elastic  tumor-mass  can  be  felt  in  the  epigastrium, 
having  an  oval  shape  with  a  horizontal  diameter  of  about  one  dm,  and  a 
vertical  diameter  of  about  four  cm.  The  tumor  is  raised  on  pulsation, 
fluctuates,  and  over  it  a  soft  systolic  murmur  is  audible.  Firm,  nodular 
tumor-masses  about  the  umbilicus  extending  to  the  right  Poupart's  liga- 
ment. The  tumor-masses  possess  respiratory  mobility.  Corresponding 
to  the  ileocecal  region  there  is  an  isolated  firm  knot  as  big  as  a  nut.  Right 
testicle  moderately  enlarged. 

Stomach  contents  (vomited)  :  HCl  positive. 
Blood:  12,100  leucocytes. 

Urine:  About  ^%  serum-albumin,  few  granular  casts  in  the  sediment, 
many  colon  bacilli. 

ad  8.— Beginning:  End  of  March,  1904. 
Status  presens:  May  6,  1904. 
Autopsy  :  May  30,  1904. 
Duration:  2  months, 
ad  9.— Autopsy  (Professor  Dr.  A.  Ghon)  :  Sarcomatous  teratoma 
of  the  right  testicle,  about  the  size  of  a  fist.    Secondary  medullary  sar- 
coma of  right-sided  inguinal,  iliac,  retroperitoneal  and  mesenteric  lymph- 
glands,  together  with  perforation  into  the  inferior  vena  cava.    Secondary 
sarcoma  in  form  of  little  knots  on  the  peritoneum  and  numerous  knots  as 
big  as  hazelnuts  in  the  liver. 

Epicrisis:  The  palpable,  tensely  elastic  tumor-mass  in  the  epigastrium, 
on  account  of  its  retroperitoneal  location,  at  first  raised  the  suspicion 
whether  it  might  not  belong  to  the  pancreas. 

The  right  testicle  was  not  at  first  thought  of  as  the  point  of  origin, 
because  of  the  patient's  statement  that  the  intumescence  of  the  right 
testicle  had  been  present  for  from  six  to  eight  years  and  had  not  under- 
gone any  change. 

Still  it  was  remarkable  that  between  the  tiunor-mass  in  the  epigas 
trium  and  the  right  testicle  there  extended  tumor-masses  like  a  bridge 
toward  the  ileocecal  region. 

Corresponding  to  the  ileocecal  region  itself,  a  tumor-mass  as  big  as 
a  nut  could  be  felt.  The  epigastric  tumor-mass  vibrated  with  pulsation : 
the  systolic  murmur  audible  over  the  tumor  probably  originated  in  the 


348  APPENDIX 

aorta  (the  aorta  passed  through  the  tumor-masses).  Despite  their  retro- 
peritoneal location  the  tumor-masses  distinctly  exhihited  moderate  respira- 
tory displaceability. 

Pain  in  the  back  or  other  neuralgic  pain  was  wanting  during  the  entire 
course. 

The  initial  symptoms  had  been  anorexia,  moderate  constipation  with 
tendency  to  meteorism,  and  acute  occurrence  of  a  venous  thrombosis  in 
the  left  leg  (while  taking  a  walk). 

Case  5. — J.  L.,  51  years,  M.    Shoemaker. 

ad   8. — Had  variola  at  '22:  denies  syphilis. 

ad  6.^ — About  March,  1899,  loss  of  appetite  set  in.  Antipathy  to 
meat,  belching  of  odorless  gases.  Vomiting  did  not  occur.  The  abdomen 
was  distended  and  tense,  especially  after  meals.  There  were  present  con- 
tinual severe  pains  in  the  back,  even  when  resting  cjuietly  and  irrespective 
of  motion  ;  originally  they  had  been  elicited  and  aggravated  by  motion. 
Almost  synchronous  with  these  symptoms  there  appeared,  in  the  left 
supraclavicular  fossa,  a  painless  glandular  swelling,  which  decreased  in 
size  after  the  application  of  hot  compresses. 

In  August,  1899,  there  also  ;i])peared  glands  in  the  right  supraclavicu- 
lar fossa;  in  September,  1899,  slight  difficulties  in  deglutition  were  no- 
ticed at  the  height  of  the  second  rib. 

ad  7. — Cachectic,  pale  gray  color  of  the  face;  great  emaciation. 
Soft  gland  tumors  on  both  sides  in  the  supraclavicular  foss;e.  Ascites 
(aspiration  fluid):  "milky"  turbidity. 

Blood:  3,100,000  erythrocytes,  \07<  hemoglobin,  14,-J()0  leucocytes 
with  only  4.7%  lymphocytes. 

During  the  course  of  a  terminally  intercurrent  infection  (perforative 
peritonitis)    the  cervical  glands  diminished   considerably   in   size   and  be- 
came   very  soft;  at  the  same  time  the  pains  in  the  back  became  less, 
ad  8. — Beginning:  INIarch,  1899. 

Status  prcsens:  October,   1899. 
Autopsy:  November,  1899. 
Duration:  About  9  months, 
ad  9. — Autopsy   (Professor  Dr.  H.  Alhrecht)  :  Lympho-sarcoma- 
tosis  of  the  glands  in  the   greater  curvature  of  the  stomach  and  in  the 
mesocolon,  extending  to  the  root  of  the  mesentery  and  into  the  spleen, 
with  consequent  ulceration  at  the  greater  curvature  of  the  stomach  and 
slight  constriction  of  the  splenic  flexure  of  the  colon.    Lymphoma  in  the 
neck,  in  the  axillary  space,  in  the  inguinal  region  of  both  sides  and  retro- 
peritoneally.   Old  tuberculosis  of  the  glands  in  the  left  mediastinum  and  the 
mesenter}'.    Chylous  ascites  and  right-sided  chylothorax. 

Epicrisis:  In  view  of  the  fact  that  among  abdominal  neoplasms  gas- 
tric cancers  most  frequently  lead  to  metastases  in  the  left  supraclavicular 
fossa,  this  possibility  had  to  be  taken  into  consideration  in  this  case  also. 
The  more  so  as  anorexia  and  disgust  toward  meat  counted  among  the 
early  symptoms.  While,  however,  the  appearance  of  "Virchow's  glands" 
is  always  amongst  the  late  s3^mptoms  of  .gastric  cancer,  the  appearance 


"ATYPICAL"    TUMORS    OF    THE    ABD0:MEX  349 

of  supraclavicular  gland  swelling  in  this  case  coincides  with  the  first  oc- 
currence of  gastric  s3'niptonis.  Remarkable  also  was  the  soft  consistence 
of  the  glands,  which  was,  later  on,  accentuated  under  the  influence  of  an 
intercurrent  infection  when  the  glands  were  reduced  in  size  and  the  pains 
in  the  back  strangely  decreased.  The  appearance  of  glandular  swellings 
in  the  right  supraclavicular  fossa  also  had  to  be  looked  upon  as  a  very 
rare  happening  in  connection  with  gastric  cancer. 

The  original  retrogression  of  the  glandular  swelling  after  the  appli- 
cation of  compresses  was  likewise  worthy  of  note. 

All  of  this,  even  during  life,  compelled  the  assumption  that  we  were 
dealing  wath  a  primary  glandular  process  affecting  particularly  the 
retroperitoneal  glands,  which  had  given  rise  to  the  severe  pains  in  the  back 
and,  through  pressure  on  the  chyle  chaiuiels,  had  led  to  a  "chylous"  as- 
cites. From  here  there  had  occurred,  via  the  thoracic  duct,  intumescence 
of  the  supraclavicular  glands.  The  temporary  difficulties  in  deglutition 
also  were  due  to  intumescence  of  the  glands  in  the  neighborhood  of  the 
upper  portion  of  the  esophagus. 

Case  6.— F.  J.,  37  years,  F. 

ad   1. — Father  died  of  cancer  of  the  stomach. 

ad  3. — Had  varicella  and  measles. 

ad  5. — In  April,  1900,  while  going  through  a  confinement,  a  tumor 
was  discovered  on  the  right  side  of  the  true  pelvis.  During  the  following 
pregnancy,  Csesarean  section  was  performed  on  March  31,  1901,  because 
the  tumor,  which  was  assumed  to  spring  from  the  connective  tissue  of  the 
pelvis  or  from  the  right  kidney,  prevented  normal  labor. 

ad  6. — About  the  middle  of  May,  1900,  there  appeared  also  pain 
in  the  liver,  and  the  patient  was  troubled  with  dyspnea.  Frequent  vomiting 
supervened,  and  there  was  disgust  toward  meat.  Since  October,  1901, 
there  was  also  vomiting  of  "coffee-grounds." 

ad  7. — Mild  subicteric  discoloration;  very  slight  edema  about  the 
ankles.  Liver  enlarged  downward  more  than  the  breadth  of  one  hand, 
the  anterior  surface  being  covered  with  very  prominent  elevations  about 
the  size  of  apples  ;  they  feel  in  part,  softly  elastic,  and  in  part  fluctuating. 
Dilated  veins  cross  the  epigastrium  and  are  continued  onto  the  sternum. 
Urine:  Abundant  urobilin. 
Blood:  13,700  leucocytes. 

Vaginal  examination:  A  very  firm,  fixed  tumor-mass,  as  big  as  an 
apple,  can  be  felt  on  the  right  beside  the  portio. 

November  10,  1901  :  Sudden  appearance  of  general  clonic  contrac- 
tions with  trismus ;  duration  about  ten  minutes.  After  this  attack  the 
power  of  speech  was  disturbed.  On  and  off  the  patient  is  not  able  to  recall 
certain  words ;  thus  she  cannot  remember  her  own  name.  When  reading 
there  are  certain  words  which  she  cannot  pronounce ;  the  less  she  thinks 
during  reading,  the  better.  The  patient  understands  perfectly  the  words 
thf^t  aro  sy)oken  to  her.  Eye  ground  is  normal.  Headache  occurring  only 
toward  the  end. 


350  APPENDIX 

ad  8. — First  symptoms:  May,  1900. 

Status  presens:  November  11,  1901. 

Autopsy:  February  2,  1902. 

Duration :  About  9  months. 
ad  9. — Autopsy  (Professor  Dr.  H.  Albrecht)  :  The  liver  enor- 
mously enlarged  (10.3  g),  presenting  on  its  surface  numerous  cystic 
tumors  as  big  as  a  man's  fist,  some  of  which  bulge  out  considerably  and 
siiow  distinct  fluctuation.  On  section  the  liver  shows  cystic  cavities  every- 
where, their  size  varying  from  that  of  a  walnut  to  that  of  a  man's  fist. 
Between  the  cysts  there  are  solid  tumor-masses,  consisting  of  soft  tumor- 
tissue  in  which  numerous  hemorrhages  have  taken  place.  In  the  island 
of  Reil  and  in  the  third  frontal  convolution  there  is  a  round,  dark-red 
tumor-mass  measuring  on  cross-section  5  cm  in  diameter. 

Epicrisis:  Clinically  we  were  dealing  with  a  very  peculiar  malignant 
cystic  alteration  of  the  liver,  which  had  led  to  great  enlargement  of  the 
organ.  The  tumor  had  given  rise  to  structurally  analogous  metastasis 
in  Broca's  speech  area.  This  accounted  for  the  repeated  epileptiform 
attacks  and  for  the  motor  aphasia.  Headache,  chiefly  on  the  left  side, 
supervened  later. 

The  histological  examination  made  by  Professor  Dr.  H.  Albrecht 
showed  that  we  were  dealing  with  a  primary  cylindrical  cell  carcinoma  of 
the  liver  springing  from  the  bile  radicals.^ 

Case  7.— Th.  S.,  39  years,  F. 

ad  5. — Was  always  healthy  until  about  August,  1908. 

ad  6 — In  August,  1908,  there  began  i)urning  pain  in  the  epigas- 
trium, occurring  mostly  one  hour  after  intake  of  food  ;  anorexia.  This 
condition  lasted  about  one  week,  after  which  the  patient  felt  entirely  well 
again.  During  the  night  of  Septemln-r  29-30,  1908,  profuse  hematemesis 
occurred,  which  caused  death  on  October  5th. 

ad  7. — October  2,  1908:  Light  brown  hair;  eyebrows  feebly  de- 
veloped; great  pallor,  tachycardia.  An  area  of  tenderness  underneath  the 
left  costal  arch. 

ad   8. — Beginning:  August,  1908. 

Status  presens :  October  2,  1908. 
Autopsy:  October  6,  1908. 
Duration:  2  months. 

ad  9. — Autopsy  (Pros.  Professor  Dr.  Fr.  Schhigenhoufer)  :  Lym- 
phosarcoma of  the  stomach  in  the  shape  of  two  tumors,  each  as  big  as  a 
hen's  ego;,  on  the  posterior  wall  of  the  stomach,  extending  to  the  lesser 
curvature,  with  extensive  ulceration.  ^Metastases  in  the  right  kidney,  al- 
most entirely  replacing  same.  Ulceration  in  the  region  of  the  hepatic 
flexure.    Bowel  filled  with  coagulated  blood.    Severe  anemia. 

Epicrisis:  While  lymphosarcomatous  diseases,  as  a  rule,  exhibit  little 


^  See  Transactions  of  the  German  Association  of  Surgery,  1897,  26th  Congress,  page 
137. — r.  Hnherer.  Zur  Frage  der  nicht  parasitaren  Lebercysten,  Wiener  Klin.  Wochen- 
schrift,  1909,  No.  51. 


"ATYPICAL"    TUMORS    OF    THE    ABD()Mi:\  351 

tendency  to  bleeding,  a  fatal  heniatcniesis  occurred  in  this  case,  and  that 
but  a  short  time  after  the  appearance  of  ulcerous  symptoms. 

The  extensive  metastasis  in  the  kidney  deserves  attention ;  at  times 
this  may  impose  as  a  primary  renal  neoplasm. 

Case  8. — M.  W.,  56  years,  M.    Innkeeper. 

ad   1. — Mother  died  at  a  very  advanced  age, 

ad  5. — Had  always  been  healthy. 

ad  6. — In  November,  1904,  the  appetite  diminished;  appearance 
became  bad.  Even  at  that  time  a  tumor  as  big  as  a  fist  was  found  in  the 
abdomen.    Xo  pain. 

Since  the  end  of  February,  1905,  there  have  been  light  sweats ;  one 
fluid  bowel  evacuation  daily;  the  color  of  the  urine  became  somewhat 
darker.    Great  emaciation, 

ad  7. — Pale-yellowish  color  of  the  face,  no  edemas,  A  firm  tumor  as 
big  as  the  head  of  a  child  can  be  felt  in  the  left  half  of  the  belly,  corre- 
sponding in  its  location  to  a  renal  tumor.  In  front  of  it,  running  in  a  ver- 
tical direction,  there  is  a  cord-like  displaceable  structure  (bowel  loop.'')  ; 
the  ascending  colon  when  distended  lies  anterior  to  the  tumor.  In  the  left 
flank  there  is  dulness  coming  from  the  tumor-mass.  The  tumor  exhibits 
moderate  respiratory  displaceability  and  is  movable  also  in  a  lateral  direc- 
tion. From  the  lumbar  region  it  does  not  permit  of  dislocation  forward, 
but  does  so  from  the  flank.  In  the  left  lumbar  region  there  is  no  dulness 
and  no  increased  resistance.  The  tumor  admits  of  demarcation  from  the 
left  costal  arch.  There  is  no  audible  systolic  vascular  murmur  over  the 
tumor.  The  right  half  of  the  abdomen  is  distended  with  meteorism  and 
isolated  loops  of  intestine  distended  with  meteorism  are  indistinctly  pal- 
pable. Tumor  not  sensitive  to  pressure.  A  big  unilateral  varicocele 
(left)  ;  testicles  normal. 

Urine:  Distinct  diazo  reaction;  no  serum-albumin,  no  casts. 
Feces:  Fluid,  light  yellow,  foamy,  acid  reaction;  containing  abundant 
Gram-positive  leptothrix  forms  partly  staining  blue  with  iodin  ;  isolated 
soap  needles. 

Stomach  contents  (after  test-breakfast):  Total  aciditj^,  2%;  %o  N. 
NaOH ;  HCl  negative. 

ad  8. — Beginning:  November,  1904, 

Status  presens :  March  8,  1905, 
Operation :  March  23,  1905, 
Duration:  About  5  months, 

ad  9. — Operation  (Hofrat  Professor  Dr,  J.  Hochcncgg)  :  Oblique 
lumbar  incision  about  20  cm  long;  after  severing  the  muscles  the  uneven 
tumor  comes  into  view ;  few  adhesions ;  hilum  cannot  be  found,  so  that  the 
diagnosis  of  a  renal  tumor  must  be  discarded.  After  extirpation  of  the 
tumor,  the  apparently  entirely  normal  kidney  can  be  seen  in  the  upper 
end  of  the  wound. 

Dissection:  A  lobulated  tumor,  as  big  as  the  head  of  a  child,  covered 
with  small  nodules,  not  sharply  excapsulated ;  on  cross  section  grayish- 
white  ;  consistence  pretty  firm. 


352  APPENDIX 

Histological  examinution:  Small  spindlc-cell  sarcoma. 

Epicrisis:  In  its  location  the  tumor-mass  resembled  a  renal  tumor  so 
perfectly  that  even  during  the  operation,  after  the  tumor  had  been  laid 
bare,  it  was  impossible  to  distinguish  with  certainty.  Only  when  it  was 
impossible  to  find  a  hilum,  the  diagnosis  of  renal  tumor  had  to  be  dropped, 
tile  intact  kidney  coming  to  light  after  the  operation  had  been  performed. 

It  is  true  that  aside  from  a  positive  diazo  reaction  the  urinary  finding 
had  been  perfectly  negative,  which  was  remarkable  in  view  of  the  size  of 
the  tumor-mass. 

On  the  other  hand,  there  were  manifestations  on  the  part  of  the  bowel, 
such  as  mcteorism,  fiuid  foamy  evacuations  having  an  acid  reaction,  con- 
taining a  peculiar  type  of  vegetation  (abundance  of  leptothrix  fornis). 
The  complete  absence  of  any  admixture  of  blood  in  the  stools,  however, 
argued  against  the  assumption  that  the  tumor  might  belong  to  the  trans- 
verse colon. 

This  case  illustrated  that  in  the  differential  diagnosis  of  malignant 
new-growths  of  the  abdomen,  one  has  to  reckon  with  the  possibility — 
though  indeed  rarely — that  tlie  tumor  does  not  spring  from  any  organ 
whatever. 

Case  9. — J.  S.,  47  years,  M.    Innkeeper." 

ad  1. — Father  and  mother  are  living  and  are  well,  so  also  four 
brotliers  and  sisters. 

ad  3. — Has  had  no  infectious  diseases. 

ad  -i. — Digestion  perfect  until  1882,  at  which  time  the  patient 
thinks  he  spoiled  it  by  drinking  cold  beer.  Since  then  there  has  been  fre- 
quent diarrhea,  sometimes  twenty  stools  a  day,  especially  after  eating 
cheese  or  flour  foods,  no  tenesmus,  no  pain;  since  then  also  tendency  to 
flatulence. 

ad  6. — On  October  30,  1897,  took  sick  suddenly  after  drinking 
black  coffee,  falling  to  the  ground  ;  appearance  of  colicky  pain  in  the  ab- 
domen. Since  then  the  abdomen  is  distended;  the  bowel  evacuations  are 
light  in  color  and  fluid.  Colicky  pain  in  the  belly  every  two  or  three 
minutes ;  the}^  start  in  the  epigastrium,  sometimes  radiate  into  the  back 
and  are  accompanied  by  lively  gurgling.  The  use  of  coffee  elicits  them 
promptly.  Pressure  on  the  abdomen  sometimes  aborts  the  pain.  Increased 
feeling  of  thirst,  no  vomiting. 

Since  the  beginning  of  January,  1898,  severe  swelling  of  the  legs. 
Great  emaciation  during  the  past  two  months  (November-December, 
1897). 

ad  7. — Color  of  the  face  pale  and  anemic,  face  bloated,  capillary 
dilatations  in  the  cheeks.  Hair  of  the  head  brown,  mustache  red.  Severe 
pallid  edema  of  the  lower  extremities.  Abdomen  greatly  distended  with 
meteorism,  including  the  lateral  portions ;  splashing  sounds  are  also 
audible.    Skin  of  the  abdomen  is  tense,  shiny.    On  and  off  big  S-shaped 

'See  R.  Schmidt,  Ein  Beitrag  zur  Lymphosarcomatosis  des  Diinndarmes.  Wiener 
Klin.  Wochenschr.,  1898,  No.  21. 


"ATYPICAL"    TUMORS    OF    THE    ABDOMEN  353 

intestinal  loops,  about  1  dcni  In  width,  bulge  out  above  and  to  the  left 
of  the  umbilicus,  disappearing  on  both  sides  under  the  costal  arches. 
Small  areas  of  dulness  in  the  flanks,  moving  with  change  in  position. 
No  tumor-mass  can  be  felt  anywhere. 

Feces:  Constantly  fluid,  very  putrid,  containing  nuuRrous  lumps  of 
mucus  as  big  as  lentils. 

Blood:  N^o  leucoc^^tosis,  erythrocytes  4,000,000,  hemoglobin  75%. 

From   January   9  to   12   there  was   a   gain   in   weight   amounting  to 
7  kg  as  a  result  of  rapid  increase  of  edema.    Death  occurred  on  January 
30,  1898,  the  diarrhea  (up  to  14  stools  a  day)  persisting  up  to  the  end. 
ad  8. — Beginning:  End  of  October,  1897. 
Status  prcsens:  January  7,  1898. 
Autopsy:  January  30,  1898. 
Duration :  3  months, 
ad  9. — Autopsy:      "Multiple,    partly    ulcerating,    partly    healed 
(cicatricized)    lymphosarcoma  of  the  small  intestine;  adhesions  between 
two  loops  of  bowel,  corresponding  to  one  ulcerating  sarcomatous  nodule, 
and  consequent  stenosis  at  that  site." 

E picrisis :  In  this  47-year-old  patient  the  symptoms  that  are  with  cer- 
tainty referable  to  the  lymphosarcoma  extend  over  a  period  of  about 
three  months.  jNIany  years  previous  there  had  existed  a  great  disposition 
to  diarrhea  which  was  provoked  by  alimentation,  which  disturbed  the  gen- 
eral health  but  little.  About  three  months  prior  to  death  there  appeared 
colics  due  to  bowel  constriction ;  rigidity  of  the  bowel  could  be  demon- 
strated objectively  and  there  was  constant  diarrhea.  The  external  aspect 
of  the  patient  presented  a  severe  general  anasarca  and  called  to  mind  the 
picture  of  the  hydropic  form  of  parench3'matous  nephritis. 

Although  the  rapid  course  of  the  disease  urged  the  assumption  of  a 
malignant  process  there  was  no  reason  for  thinking  at  once  of  a  Lympho- 
sarcoma of  the  small  intestine.  For,  as  Kiindrat  had  already  pointed  out, 
lymphosarcomas  do  not  usually  run  along  with  narrowing  but  with  dila- 
tation of  the  intestinal  tube. 

As  autopsy  showed,  the  stenosis  was  due  to  adhesion  between  two 
loops  of  intestine,  corresponding  to  an  ulcerating  sarcomatous   nodule. 

The  localization  of  the  stenosis  also  met  with  difficulties ;  the  areas  of 
splashing  in  the  flanks  could  suggest  the  possibility  of  dilatation  of  the 
colon  and  thus  of  a  stenosis  low  down  (sigmoid  flexure .'*)  ;  the  coils  of  intes- 
tine  rearing  with  peristalsis  were  characterized  by  particular  breadth. 

Autopsy,  however,  showed  that  the  stenosis  was  situated  in  the  upper 
ileum  and  "permitted  of  passage  of  only  one  finger."  The  sarcomatous 
infiltration  of  the  small  intestine  had  not  been  palpable  during  life. 

Case  10.— B.  C,  25  years,  M. 

ad   1. — Father  died  of  hemoptysis  at  36. 

ad  2. — The  riglit  eye  bears  evidence  of  a  former  keratitis  paren- 
chymatosa ;  Hutchinson  teetli. 

ad  3. — During  childhood  had  smallpox ;  three  years  ago  acquired 
syphilis. 


354  APPENDIX 

ad  5. — Was  otherwise  healthy. 

ad  6. — In  February,  1895,  there  began  stomach  coniphiints,  namely 
pain  in  the  epigastrium  in  connection  with  meals,  lasting  about  one  hour. 
Appetite  good,  bowels  regular. 

About  the  middle  of  March,  1895,  edema  was  noticeable  in  the  feet, 
soon  also  in  the  legs  and  thighs.  The  appetite  disappeared;  on  and  off 
yellow  biliary  vomiting.    Emaciation. 

ad  7. — A  pale  appearing,  frail  individual.  On  the  right  side  of  the 
neck  there  is  a  large,  moderately  hard,  indolent  gland.  Diminished  reson- 
ance over  both  pulmonary  apices.  Abdomen  distended,  moderately  tense, 
not  sensitive  to  pressure;  a  striking  tympanitic  resonance  over  the  epi- 
gastrium. The  spleen  passes  two  finger  breadths  below  the  costal  arch. 
Edema  of  the  belly-wall  from  the  umbilicus  downward. 

Blood:  2,100,000  erythrocytes,  307r  hemoglobin,  slight  leucocytosis ; 
no  eosinophile  cells  can  be  found. 

Stomach  contents  (vomited) :  HCl  positive. 
Subfebrile  course  with  a  single  rise  of  temperature  to  38.4-     C. 
ad  8. — Beginning:  February,  189.5. 

Status  presens:  IMay  7,  1895. 
Autopsy:  May  23,  1895. 
Duration:  About  4  months. 
ad  9. — Autopsy:  The  upper  portion  of  the  jejunum  for  a  distance 
of  about  60  cm  changed  into  a  wide,  thick-walled,  rigid  tube  as  a  result 
of  Infiltration  of  the  bowel-wall  by  a  milky  white,  unconunonly  soft  ma.ss 
winch  in  the  portion  toward  the  bowel  lumen  has  partly  undergone  necro- 
tic  softening,  the  intact  knobs  bulging  out.    The   respective  mesenteric 
glands  are  greatly  enlarged,  uncommonly  soft,  exhibit  pseudo-fluctuation. 
Enlargement  of  all  the  solitary  follicles. 

Anatomical  diagnosis:  Lymphosarcomatosis  of  the  upper  end  of  the 
jejunum.  Tuberculosis  of  the  lymph-glands.  Infiltration  of  the  left  pul- 
monary apex. 

Epicrisis:  In  this  25-year-old  tubercular  patient  one  was  tempted  to 
interpret  the  abdominal  findings  as  a  bowel  or  peritoneal  tuberculosis. 

As  in  Case  1,  a  tumor-mass  was  not  palpable  here,  which  is  probably 
explained  by  the  more  uniform  surface  infiltration  of  the  bowel-wall  and 
by  the  particular  softness  of  the  infiltrating  pseudo-mass.  The  rapid 
course  of  the  disease,  however,  as  well  as  the  early  appearance  and  rapid 
development  of  the  edemas  (thigh  and  abdominal  wall),  were  remarkable. 
BoAvel  symptoms  did  not  appear  at  all,  symptoms  of  constriction  es- 
pecially being  absent ;  the  epigastric  localization  of  the  disease  manifes- 
tations (pain  after  meals  with  much  local  meteorism)  could  simulate  a 
gastric  disease,  but  at  autopsy  were  shown  to  be  due  to  greatly  dilated, 
lymphosarcomatous  coils  of  small  intestine. 

It  seems  to  me  that  this  case  illustrates  that,  In  remarkably  rapid 
cases  of  apparent  peritoneal  tuberculosis,  accompanied  by  severe  edemas, 
the  possibility  of  lymphosarcomatosis  of  the  small  Intestine  should  al- 
wavs  be  borne  in  mind. 


"ATYPICAL"    TUMOllS    OF    THE    ABDOMEN  355 

Case  11.— Ch.  K.,  28  years,  M.    Merchant.' 

ad   1. — Mother  died  of  "hardening  of  the  hver"  at  4-8. 

ad  2. — In  cliiidhood  always  had  a  pale  appearance,  swelling  of  the 
cervical  glands,  intlannnation  of  the  eyes. 

ad  8. — Had  no  infectious  diseases  of  childhood.  It  is  said  that  in 
Deceniher,  1905,  he  had  an  eruption  on  the  head,  back,  scrotum  and  anus, 
with  formation  of  a  crust;  ulcers  also  in  the  mouth.  A  ten-day  inunction 
with  mercurial  ointment  and  potassium  iodid  therapy  produced  im- 
provement. 

ad  4i. — Always  had  a  disinclination  toward  fatty  foods;  they  pro- 
duce diarrhea.    Otherwise  the  appetite  is  good  and  bowels  regular. 

ad  6. — About  the  end  of  September,  1900,  there  began  cramp-like 
pain  in  the  abdomen,  being  localized  about  the  umbilicus ;  the  abdomen 
became  somewhat  sensitive  to  pressure.  Defecation  and  urination  were 
somewhat  difficult.  The  patient  himself  noticed  knobby  tumors  in  the  belly. 
Toward  the  end  of  December,  1906,  biliary  vomiting.  ^leat  anorexia 
since  the  end  of  November  (the  patient  likes  to  eat  ham  only).  Otherwise 
the  appetite  is  good. 

ad  7. — January  27,  1907 :  Color  of  the  face  whitish-gray,  no  yel- 
lowish tint.  Hair  dark  brown  ;  teeth  good.  Nodular  tumor  masses  occupy- 
ing the  greater  portion  of  the  inferior  abdominal  region ;  they  vibrate 
with  pulsation,  especially  those  on  the  left  side ;  there  is  also  a  systolic 
vascular  murmur.  Diffuse  splashing  in  the  bowel ;  no  bowel  peristalsis. 
No  distinct  ascites.  Anemic  heart-murmurs,  venous  hums,  jumping  pulse. 
No  enlarged  glands.  Retromalleolar  edema.  Slight  temperature  rises  over 
37°  C. 

March  1,  1907:  Severe  ascites  with  hydrothorax  and  great  pallor; 
soft  edema  of  the  leg  and  thigh  and  in  the  lumba'r  region.  Tumor-mass 
soft,  slightly  uneven,  situated  around  the  umbilicus,  covering  an  area 
bigger  than  the  palm  of  a  hand ;  over  this  there  is  tympanitic  resonance. 
Extensive  splashing  on  succussion.  No  symptoms  of  bowel  constriction. 
Temperature,  as  a  rule,  a  little  over  37°  C. 

Feces:  Bowel  movements  daily,  copious,  of  gray  color  and  fatt}'  lustre 
(no  icterus)  ;  no  admixture  of  mucus  or  pus.  The  bowel  flora  consists 
almost  exclusively  of  lactic-acid  bacilli,  which  also  yield  a  rapid  growth 
on  culture. 

Urine:  Diazo  reaction  frequently  very  distinctly  positive. 
Stomach    contents    (vomited)  :   Only   isolated    rod-shapes    resembling 
lactic-acid  bacilli ;  tubular  yeast  cells. 

Blood:  60%  hemoglobin,  9,600  leucocytes,  of  these  17%  are  large 
mononuclear  forms. 

ad  8. — Beginning:  End  of  September,  1906. 

Status  presens:  January  27,  1907,  and  March  1,  1907. 
Autopsy:  April  4,  1907. 
Duration :  About  6  months. 


'  See  Mitteil.  d.  Ges.  f.  innere  Med.  u.  Kinderheilk.,  Wien,  1907,  page  107. 


356  APPENDIX 

ad  9. — Autopsy  (Professor  Dr.  A.  Ghon)  :  Dilatation,  about  the 
size  of  a  child's  head,  in  the  uppermost  part  of  the  jejunum;  the  bowel- 
wall  in  that  locality  lymphosarcomatously  infiltrated.  The  spleen  is  small, 
the  follicles  of  the  tongue  not  swollen.  Kidney  is  lobulated,  the  aorta 
somewhat  narrowed,  the  thickness  of  its  walls  being  diminished.  Chylifonn 
ascites  and  chronic  peritonitis.  Chyliform  right  hydrothorax.  Throm- 
bosis of  the  femoral  vein. 

Epicrisi.s:  The  following  three  findings  during  life  prompted  me  to 
make  the  diagnosis  of  lymphosarcoma  of  the  small  intestine: 

1.  The  presence  of  soft  tumor-masses  in  the  abdomen,  the  malignant 
nature  of  which  could  hardly  be  doubted  in  view  of  the  accompanying 
ascites,  severe  edemas,  etc. 

2.  The  finding  of  a  very  abundant  flora  of  lactic-acid  bacilli  in  the 
feces  with  almost  negative  bacteriological  findings  in  the  stomach  contents. 
This  suggested  that  the  peculiar  intestinal  vegetation  was  not,  as  is 
mostly  the  case,  of  gastric,  but  of  intestinal  origin.  Combined  with  the 
first  finding  it  led  to  the  assumption  of  an  intestinal  neoplasm. 

3.  The  absence  of  all  symptoms  of  constriction  when  there  were  indi- 
cations of  dilatation  of  the  bowel  (constant,  extensive  bowel  splashing  on 
succussion  of  the  abdomen). 

It  is  well  known  that  precisely  lymphosarcomas  frequently  go  along 
without  symptoms  of  stenosis. 

In  addition  there  was  the  youthful  age  of  the  patient  (28  years)  ;  the 
fact  that  during  youth  there  had  been  signs  of  lymphatismus  (swelling  of 
glands!  eye  inflammations)  also  entered  into  consideration. 

Autopsy  also  disclosed  congenital  peculiarities,  in  so  far  as  the  kidne\'s 
were  peculiarly  lobulated  and  the  aorta  was  found  to  be  narrow  and  thin- 
walled. 

The  copiousness  of  the  stools,  as  well  as  their  fat  content,  are  prob- 
ably to  be  attributed  to  poor  absoi*ptive  conditions;  for  that  matter 
there  was  neither  diarrhea  nor  constipation. 

Admixtures  of  mucus,  pus  and  blood  were  absent,  it  being  hardly 
possible  to  demonstrate  any  ulceration  in  the  infiltrated  area  of  the 
bowel. 

The  syndrome :  "Ascites  and  diazo  reaction,"  which  in  other  cases  is 
usually  referable  to  tubercular  peritonitis,  was  in  this  instance  due  to 
lymphosarcoma. 

The  high  percentage  of  large  mononuclear  forms  in  the  blood  is  de- 
serving of  note ;  it  is  a  symptom  which  is  at  least  suspicious  of  lympho- 
sarcoma. 

The  finding  of  hyperplasia  of  the  follicles  at  the  base  of  the  tongue, 
not  rare  in  these  cases,  was  not  present  in  this  instance. 


THE  COPYRIGHTS  OF  THIS  BOOK,   IN  ALL  ENGLISH-SPEAKING  COUNTRIES,   ARE 
OWNED  BY  REBMAN  COMPANY,   NEW   YORK 


Index 


Abdomen,   physical   examination   of,    1 
pseudo-malignant  diseases  of,   10 
Abdominal   tumors,  atypical  malignant,   165 
Abscess,  cold,  12 

of    abdominal    wall    In    gastric    cancer, 

77,  lot 
subphrenic,  in  gastric  cancer,  85 
Achlorhydria,  93,   129 
Actinomycosis,  ileocecal,  12 
Addison's  disease,  icterus  in,  10 
Addison-like  discolorations,  43,  90,  103 
Adynamia,  42 
Age,  132,  141 

in  etiology  of  malignant  growths,  49 
Aldehyde  reaction,  33,  36,  130 

in   biliary   obstruction,  35 

significance  of,  36,  37 
Alimentation,    effect   of,   on    pain,    71 
Amyloidosis,   131 
Anemia,  pernicious,   10,   87 
Anesthetics,  1 
Angiosderosis,  89 
Anorexia,   75,    129,    149 
Aorta,  abdominal,  5 

in  cancer  of  the  pancreas,  150 

origin  of  murmurs,  5 
Appendicitis,  122,  154 
Appendix,  cancer  of,  168 
Appetite  in  gastric  cancer,  74 
Ascites,  5 

examination  of  umbilicus   in,  5 

in  cancer  of  the  gall-bladder,  139 

in   cancer  of  the   pancreas,   150,   152 

in  gastric  cancer,  85 

in  hepatic  cancer,  129 

in  ovarian  tumors,  169 
Atelectasis  of  lungs  in  gastric  cancer,  89 
Atheromatous  changes  in  gastric  cancer,  86 
Atrophy  of  lingual  mucosa,  83 
Auscultation,   in   gastric   cancer,   81 

in  cancer  of  large  intestine,  116 

in  renal  neoplasms,  158 
Azotorrhea,  148 

Bacilli,  lactic-acid,  20,  24,  92 

Back,  pains  in,  71 

Bacterium  coli,  in  gastric  cancer,  29,  92 

Balloon-like  stomach,  76 

Ballottement,  4 

in  corset  lobes  of  liver,  4,  138 

in  stomach  timiors,  4,  80 

of  kidney  tumors,  157 
Biliarj'  congestion,  35,  134 
Biliary  obstruction,  35 


Bladder,  urinary,  2 

in  intestinal"  cancer,  119 

in  kidney   tumors,   160 
Blood   in   feces,  chemical   i)roof  of,   U 

in  gastric  cancer,  63,  91,  132 
Bone  tumors,  105,  120,  163 
Borborygiui,  81 
Bradycardia,  86 
Breathing,  diaphragmatic,  3 

Cachexia,  37 

Calculi,    142,   151 

Cammidge  reaction,  148 

Cancer  and   tuberculosis,  53 

Carcinomaphobia,  59 

Cecum,  tuberculosis  of,  123 

Cell  disposition,  47 

Cercomonas  intestinalis,  28 

Chemical  irritants,  53 

Cholangitis,  31,   142 

Cholelithiasis,  31,  135,  154 

Circulatory  system  in  gastric  cancer,  85 

Cirrhosis,  Laennec's,  5,  32,  130,  144 

biliary,   131,   142,   151 

enlargement  of  epigastric  veins  in,  5 

in  etiology  of  cancer,  51 
Climate,  52,  59 
Coated  tongue,  83 
Cocci,  in  neoplasms  of  the  bowel,  30 

in  pernicious  anemia,  30 
Coffee-ground  vomiting,  69,  91,  112,  129 
Cohnheim's  theory,  47 
Colic,  attacks  of,'  106,  122,  134 

gall-stone,  140 
Collateral   circulation,  portal,   127 
Colon  bacillus,  30,  92 
Colon,  carcinoma   of,   105 
Colon,  in  renal  tumors,  157 
Color  of  face,  40 
Constipation,  84,  123,  139 
Course  of  gall-bladder  cancer,   141 
Course  of  gastric  cancer,  98 
Course  of  intestinal  cancer,  121 
Course  of  kidney  tumors,  160 
Crises,  gastric,   16 
Cystic  kidney,   164 

Danger  of  infection  in  cancer,  57 

Deglutition,  difficult,  in   gastric  cancer,  83 

Desmoidrcaction,  Sahli's,  96 

Diabetes  mellitus,  152 

Diagnosis  of  gastro-intestinal  cancer,  early, 

63 
Diaphragmatic  tumors,  167 


357 


358 


INDEX 


Diarrhea  in   jrastric  canci-r,  84 
Diathesis,  heinorrliagic,   17 

in  etiology  of  growths,   Ki,  51 
Diazo  reaction,  30,  32,  144 
Differential    diagnosis,    in    cancer    of    gall- 
bladder,  i:}(),   141,   14i2 

in  cancer  of  large  intestine,  l-2\ 

in  cancer  of  liver,  130 

in  cancer  of  pancreas,  151 

in  cancer  of  stomach,  99 

in  kidney  tumors,  161 
Digital  examination  of  the  rectum,   113 
Discolorations  of  the  skin,  A3 
Distention   i)ains   in   gastric   cancer,  70,  73 
Disturbances  of  gastric  motility,  64 
Ductus  cl)oled(K-hus,  135,  152 
Duodenal  cancer,   168 

Duodenum,  in  cancer  of  the  i)ancreas,   152 
Duration  of  gastric  cancer,  98 

of  cancer   of  tiie    gall-bladder,   140 

of  cancer  of  the  large  intestine,  121 

of  kidney  tumors,  160 

Echinococcus  cysts,  132,  142 
Edema,  43,  88  ' 

latent,  43,  90 
Effervescent  mixtures,  2 
Effusion,   hemorrhagic   ])leural,   10 
Emaciation,  38,  40 
Endocarditis,  104 

Endogenous  causes  of  neoplasms,  49 
Enteric   fever,  diazo-reaction   in,  31 
Epigastric  jnilsation,  in   gastric  cancer,  77 
Eructation  of  gas,  67 
pjsophageal  varices,  131 
Esophagus,  carcinoma  of,   104 
Etiology  of  malignant  tumors,  45 
Exogenous    injuries    exciting    inflammation, 

47 
Exogenous  local   causes  of  neoplasms,  53 
Exudate,  inflammatory,  12 

in  appendicitis,  12 

Face,  color  of,  90 

Febrile  urobilinogenuria,  35 

Fecal  vegetation  in  neoplasms  of  the 
bowel,  29 

Feces  and  stomach  contents  in  gastric  can- 
cer, 90 

Feces  in  cancer  of  the  large  intestine,  117 

Fecundation  theories,  46 

Fever,  44,   121,   123,   135,   160 

Fibroma,  11 

Fibrosarcoma,  11 

Fistula,  rectovesical,  12,  119 

Friction,  perihepatic,   142 

Friction-sounds,  peritoneal,  5,  81,  129 

Fulness,  gastric,  65 

Gall-bladder,  158 

carcinoma  of,  105,  124,  133 
early  symptoms  in  cancer  of,  133 
physical  examination  of,  136 

Gall-stones,  53 

Gastralgia,  73,  146 


Gastric  cancer,  beginning  of,   163 

Gastric    stagnation,   symptoms   due   to,  65 

Gastric  ulcer,  53,  101 

Gastritis,   chronic,  93 

Genito-uriiiary  system  in  gastric  cancer,  88 

Glycosuria,  in  cancer  of  the  pancreas,  150 

Gout,  acute,   101 

Gram-positive  bacilli  in  feces,  24 

Gumma,  liver,  13,  132 

Gurgling,   72 

Hallux  valgus,  90 

Hausemann's  anaplasia,  49 

Heartburn,  68 

Heberden's  nodes,  90 

Hematogenous   urol)ilinogenuria,  35 

Hematuria,  154,   155 

Hemiplegia,  103 

Hemorrhage,  occult    intestinal,   8 

after  lavage  of  stomach,  17 

arrest  of,  improl)abilitv  of  malignancy, 
18 

from  gums,  16 

from   nose,   16 

from   i)iles,   16 

in   cancer  of  large   intestine,   112 

in  cancer  of  jiancreas,  149 

in  cicatricial  jnloric  stenosis,   17 
Hemorrhagic  diathesis,  17 
Heredity,  50 

Hernias  in  linea  alba,  in   gastric  cancer,  77 
Hi)i|>ocratis,    succussio,   4 
Hydrochloric   acid,  70,  74,  93,  96 
Hygiene,  general,   in   cancer,  89 

local,  in  cancer,  58 
Hyperleucocytosis,  144 
Hy])ernephroma,   154,   158 
Hyi>ochlorhydria,  signs  of,  in   feces,  96 

Icterus,  catarrhalis,  151 

in  cancer  of  the  ]>ancreas,  146 

in   gall-bladder  cancer,   135,  141,  142 

in   gastric  cancer,   85 

in  hepatic  cancer,  127,  132 
Ileus,  acute,  123 
Increase  in  weight,  39 
Indican,  144,  148 
Infectious    diseases    in    etiolog}'    of    cancer, 

52,  56,  86 
Inflammation,   chronic,   in   etiologj'^   of   can- 
cer, 54 
Inflation  of  stomach,  2 
Insomnia,   89 
Intestinal  peristalsis,  in   gastric  cancer,  76» 

84 
Intestinal  tract,  sjinptoms  from,  in   gastric 

cancer,  84 
Intestine,  large,  carcinoma  of,  106 
Iris,  89 
Irritants,  chemical,  54 

Kidney,  artificial  dislocation  of,  156 
cystic,  164 

malignant  tmnors  of,  153 
physical  examination  of,  156 


INDEX 


359 


Kidney,  respiratory  iii<>l)ility  of,  157 

thherciilosis  ot.   Hi  J 

urinary  sediment  in   tumors  of.   IM 
Klel)S,  fecundation  tiieory  of.   Hi 

Lactic-acid  bacilli,  21,  22,  23 

culture  of,  25 

diagnostic  significance  of,  25 

Gram  stain,  24 
Large  intestine,  carcinoma  of,  106 

early  symptoms  in  cancer  of,  10(5 

feces    and    stomach   contents    in    cancer 
of,  117 

physical  examination   in  cancer   of,   113 
Latency  of  gastric  tumors,  78,  99 
Lavage,  17,  (U,  90 
Leptothrix,  23,  24 
Leucocytes,   in   hepatic  cancer,   130 
Lingual  mucosa,  atro])hy  of,  83 
Linitis  plastica   Brinton'.  29,  80,  85 
Lipoma,  submucous,  11 
Liver,  abscess  of,  103 

carcinoma  of,  125 

corset  lobes  of,  10,  123.  137 

fatty,    130 

gastro-intestinal     svuijitoms     in    cancer 
of,  129 

in  cancer  of  the  pancreas,  150 

in  gastric  cancer,  85,  89 

in   intestinal  cancer,  120,  124 

physical  examination  of,  127 
Local  hygiene  in   cancer,  58 
Loss  of  weight,  38 
Lues,  in  etiology  of  cancer,  53 
I-umljago,  "pseudo,"   153 
Lumbar  region,  pain   in,  71,  109 
lAmgs,  in  cancer,  89 
LjTnphatic  system  in  gastric  cancer,  87 
Lymph-glands  in  intestinal  cancer,    120 
Lymphogenous  metastasis,  159 
LjTiiphosarcoma,  1(55 

Mechanical   traumas   in   etiologv   of  cancer. 

53 
Megastoma  entericum,  28 
Melanosis,  90 
Melanin,  130 
Melena,  alimentary,  15 

in  cancer  of  the  pancreas,  149 
Meningitis,   104 
Mesentery,   81 
Metastases,  in  gastric  cancer,  88,  89 

in  kidney  tumors,  159 

lymph-giands,  120,  139 
Meteorism,   gastric,  ()9 

Microscopical  examination,  of  stomach  con- 
tents, 95 

of  feces,  118 
Mind    and  emaciation,  38 
Mind,  in  etiology  of  cancer,  52 
Moliihty  of  gastric  tumors,  80 

of  gall-l)ladder  tinnors,   137 
Motility,  disturbances  of  gastric,  (54 
Motor  ap])aratus.  90 
Motor  fimction  of  bowel,  disturbed,   110 


.MiunniificatiMii,   H!),   i»7 
Murmurs  in  renal  tumors,  158,  1(53 
Murmurs,    systolic,    in    gastric    and    liej>atic 
cancer,  5,  82,  8(5,  I2H 
systolic,  in  cancer  of  pancreas.   150 
Musclc-fil)res  in   tVct-s,   U!) 

Nclaton  tumor,   II 

Nei)hritic   sedimentary   findings,   15(» 

Nephritis,   1(53 

Nepiirolithiasis,   1(52 

Nervous  system  in  gastric  cancer,  89,  90 

Neuralgia,  103 

Neurasthenia,  39,  103 

Neuroses,  gastric,  101 

Neutral  fat,  144,  148 

Night-sweats,  44,  90,  121 

Obstijiation   in   gastric  cancer,  84 

in  gali-l)ladder  cancer,   139 

in  intestinal  cancer,  123 
Occult   renal   hemorrhage,   155 
Omentum,  infiltrated,  81,  138 

sj)ontaneous  swellings  of,   13 

tiunors  of,   1G8 

tumors  of,  after  herniotomy,  13 

tiunors  of,  after   pelvic   peritonitis,   13 
Ovaries,  tumors  of,  105,  169 
Ovum,  46 

Pain,  cessation  of,  in   beginning  cancer,   74 

in  cancer  of  the  pancreas,  145,  151 

in  gall-bladder  cancer,  133,  141 

in  gastric  cancer,  69 

in  bcjiatic  cancer,  128 

in  intestinal  cancer,  106 
Paleness,   41 
Palpation,  1,  2 

in  gall-bladder  cancer,  136 

in   gastric  cancer,  78 

in  intestinal  cancer,  113 

of  ividney  tumors,  163 
Pancreas,  carcinoma  of,  144,  145 
Pancreatic    juice,  obstructed   flow  of,   146 
Papilla  of  Skater,  144,  152 
Percussion,   5 

in   gastric   cancer,  81 

in   intestmal  cancer,  116 
Peristalsis,   visible   gastric,  76 

intestinal   in   gastric  cancer,  84 

in   intestinal   cancer,   114 
Peritoneum  in   gastric  cancer,  85,  101 

in   intestinal   cancer,   120 
Pernicious  anemia.  102 
Pigment  anomabes,  40,  42    ♦ 
Pigmentation    of    skin    in    cancer    of    ])an- 

creas,  150 
Plethora  in  cancer,  41 

Pleural   complications   in   gastric   cancer.   88 
Pleuritis,  132 
Polypi,  6 
Polyuria,  88 
Portal    veins,    co-ieestion    of   bleeding    in.    17 

thrombosis  of  lileeding  in.  17 
Positions,   painful.   109 


3(50 


INDEX 


Primary   cholangitis,   142 
Prophylaxis  of  malignant  tumors,  57 
Pulsation  of  tumors,  114 

epigastric,   77 
Pylorus,  cancer  of,  9-2 

liver  dulness  in  stenosis  of,  5 

spasms  of,  78 

stenosis  of,  5,  17,   144 
Pyonephrosis,  1()4 


Questions   in    history-taking   of   cancer    pa- 
tients, 55 


Radiology,  7,  8 

and  quackery,  7 

dangers  in,  7 

in  etiology  of  cancer,  54 

psychological    factor   in,   7 
Hectoronianoscopy,  6 

Rectum,  carcinoma  of,   105,   113,  h22,   124 
Regurgitation,    ))hcnomena    of,   67 
Renal   hematuria,   155,  162 
Renal  ischias,  154 
Renal  neoplasms,  105,  123 
Respiratory  mobility,  3,   157 
Retrojieritoiieal    ghi'nds,    139,   151,   165,   169 
Rihbert's   theory,  48 
Riegel's  test,  94 


Sahli's   desmoid  reaction,  96 
Salivation,   in   gastric   cancer,  83 
Saproi)hytes,  20 
Sarcinae,  6 

diagnostic  significance  of,  27,  67 

Good  sir,  21 

in  cancer  of  the  pancreas,  149 

of   the   stomach,   26,  92 
Sarcoma,  165,  167 
Schaper's  indiftVrcnce  zones,  48 
Scrotal  pain  in  kidney  tumors,  154 
Scyhala,  3,  10 
Secondary   infections,  32 
Secretions,   state   of,   in   gastric   cancer,  93 
Skin,  in  gastric  cancer,  89 
Skin    pigmentation    in    cancer    of   pancreas, 

150 
Small  intestine,  cancer  of,  167 
Smell,  in   diagnosis,  6 
"Soft"  hepatic  cancer,  127 
Specific  causes  of  disease,  45 

symptoms,  25 
Spirochetes,  in   neoplasms  of  the  bowel,  30 
Splashing  sounds,  4 
Spleen,  tumors  of,  165 

in  cancer  of  pancreas,  150 

in  gall-bladder  cancer,  140 

in  gastric  cancer,  87 

in  hepatic  cancer.  130,   132 

in  tumors  of  the  kidney,  158,  163 
Sputum,  hemorrhagic,   16 
Squirting  sounds,  78 
Stagnation,  gastric,  91 


Stasis  of  biliary   and   pancreatic  secretions, 

146 
Status  Ivmphaticus,  165 
Steatorrhea,    148 
Stomach,  carcinoma  of,  63 

constitutional  peculiarities  in  cancer  of, 
76 

contents,  examination  of,  95 

contents    in    gastric    cancer,   90,    117 

early  symptoms  in  cancer  of,  63 

hour-glass,   8 

in   kidney  tumors,  160 

physical  examination  in  cancer  of,  76 

resection,   93 

sarcoma  of,  167 

spastic   hour-glass,   8 
Stools,  in  cancer  of  large  intestine,  117 
Strumous  nodules,  87 
Suprarenal  disease,  42 
Suprarenal  tumor,   164 
Symjitomatology   of  cachexia,  37 
Symptoms,    gastric    and    intestinal    in    gall- 
bladder  cancer,    138 

gastro-intestinal    in    hepatic   cancer,   129 
Syphilis,  in  etiology  of  cancer,  53 


Tachycardia,  Sd,  139 
Teeth,  in   gastric  cancer,   83 
Teint  jniille  jaunc,  40 

Tem])eraturc    of    body    in   malignant   condi- 
tions, 44,  i;{5 
Tenderness  on   pressure,  73,   109,   126 
Test.    Esbach's,   64 

Mueller  and   Schlecht,   147 

Salomon's,  64 

Weber's,   15 
Testicle,  timiors  of,  169 
Tetanic  attacks,  89 
Theories   of   fecundation,   46 

C'ohnlieim's.  47 

Ribbert's,  48 

Thiersch's,  49 
Thermophore,  1 
Thirst,  in   gastric   cancer,  75 
Thrombosis,   in   gastric  cancer,  87 
Toepfer's   reagent,  94 
Tongue,   coated,   83 
Transmission  of  gastric  cancer,  50 
Traumas,  in   etiology  of  cancer,  51,  53 
Trichobezoar,    11,   101 
Tubercular   serositis,    102 
Tuberculosis,  senile,   10,  103 

gland,  in  abdomen.   12 

in   differential  diagnosis,   102 

of  peritoneum,  3 

omental,   12 

predisposing  to  cancer,   50,   53 

renal,  162 
Types,  of  gall-bladder  cancer,  140 

of  gastric   sarcinae,   27 

of  gastric  tumors,  79,  88,  97 

of  intestinal   cancer,   121 

of  kidney    tumors.    160 

of  lactic-acid  bacilli,  24 

of  pain  in   eastric  cancer,  70 


INDEX 


361 


Uffelmann's  test,  94 
Ulcer,  gastric,  2,  53,  101 
Uratic  diathesis,  51 
Ureteral  colics,  154 
Urinary  analysis,  38 
Urobilinogen,"  33,  42,  34 
Urobilinogenuria,  35,   135 

Valvular  lesions  in   gastric  cancer,   86 
Varicocele,   120,   159 
Vegetations,   gastric,   in    feces,  21,  29 
Veins,   enlargement   of   epigastric,   5 
Vena  cava,  conij)ression  of,  139 
Vertebral   column,  pains   in,   71 


Virchow's   gland,  87 

Visible  gastric  peristalsis,  76 

\'oiiiitiiig,  ((iflcc-ground,  69,  91,   112,  129 

feculent,    69 

in   gall-hladder  cancer,   134 

in   gastri<'   cancer,  68,  91 

in  intestinal  cancer,  112 

Warm   bath   in   examination   of   abdomen,    1 
Watery   eructation,   68 
Weight,  38 

X-rav   examination,  7 


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